Higher Rate Of Major Complications Research Articles

Optimal Management of Resectable Pancreatic Head Cancer in the Elderly Patient: Does Neoadjuvant Therapy Offer a Survival Benefit?

Neoadjuvant therapy (NAT) is a growing strategy for patients with resectable pancreatic ductal adenocarcinoma (PDAC). Elderly patients are at increased risk of treatment withdrawal due to functional decline, and the benefit of NAT in this cohort remains to be studied. The objective of this study was to compare outcomes of elderly patients with resectable head PDAC who underwent NAT or a surgery-first (SF) approach. All patients 75 years of age and older with radiographically resectable (National Comprehensive Cancer Network criteria) PDAC who underwent pancreaticoduodenectomy at a single institution from 2008 to 2017 were analyzed. Baseline characteristics and perioperative outcomes were compared between the SF and NAT cohorts. Recurrence-free survival and overall survival (OS) were analyzed by treatment strategy. Overall, 158 patients were identified: SF cohort=90 (57%) and NAT cohort=68 (43%). Patients in the SF cohort were older (80 vs. 78 years; p=0.01) but there were no differences in preoperative comorbidities or frailty indices. SF patients had a trend toward higher rates of major complications (38% vs. 24%; p=0.06) with higher Comprehensive Complication Index totals (20.9 vs. 20; p=0.03). There were similar rates of adjuvant therapy. NAT was associated with significantly longer OS (24.6 vs. 17.6 months; p=0.01) in both the intent-to-treat and resected cohorts. On multivariable analysis (MVA), NAT remained an independent predictor of OS (hazard ratio 0.60; p=0.02). NAT is safe and effective for elderly patients with PDAC. This study suggests NAT is associated with fewer complications after surgery, equal rates of adjuvant therapy receipt, and increased OS over a surgery-first approach.

Abstract PS1-23: Pre-pectoral implant-based reconstruction and adjuvant radiation therapy - Surgical outcomes from a multicentre study in United Kingdom

Abstract BackgroundPre-pectoral implant-based reconstruction is the most common form of reconstruction performed in the United Kingdom (UK) after a mastectomy. Implant-based reconstruction is relatively contraindicated in patients known to require adjuvant radiation therapy. There is limited data on surgical outcomes in patients with pre-pectoral implant-based reconstruction who received adjuvant chest wall radiotherapy. We present early post-operative outcomes of in this subset of patients in a large multicentre audit on prepectoral implant based reconstruction. MethodsA retrospective multi-centre audit of all post-mastectomy prepectoral breast reconstruction (PBR) using Braxon® acellular dermal matrix was conducted. The demographic details, treatment details, 90-day complication rates and implant loss rates for the entire study period were evaluated. A subset analysis of patients who required adjuvant radiation therapy was performed. Complications were categorized as major and minor based on the Clavien-Dindo classification. All complications grade III or higher were regarded as major complications. Complications reported after 90 days of the reconstruction, were regarded as delayed complications. Implant loss rates were compared to the subset of patients who did not receive adjuvant radiation therapy. ResultsEight hundred and twenty two patients underwent 1020 post-mastectomy PBR across 29 centres in the UK from January 2014 to 2019. Of these, 166 (16.28%) reconstructions received adjuvant radiation therapy. Median follow-up period was 18 months for this cohort. Median age was 49 years and the median body mass index was 25 kg/m2. Fifty-six (33.73%) patients had an axillary nodal clearance. Median hospital stay was 1 day. One hundred and twenty eight (77.11%) patients had a single stage reconstruction and 93 (56%) patients received adjuvant chemotherapy. The 90-day major complication rate was 16.26%, readmission rate and return to theatre rate was 14.45% each. Delayed complications were reported in 8.43% patients. The implant loss rate was 7.83% for the entire study period. This was comparable to the implant loss rates in the subset of patients without adjuvant radiation therapy (p = 0.366). Patients with a 2-stage reconstruction had a higher major complication rate (22.71%) as compared to single stage reconstruction (16.40%), which was statistically not significant (p = 0.469). ConclusionImplant-based PBR with acellular dermal matrix has comparable outcomes in patients undergoing adjuvant radiation therapy in terms of early outcomes. Patient reported outcomes need to be evaluated along with incidence of capsular contractures and the possible needs for additional delayed surgical interventions in this group of patients. Larger studies are needed to confirm the findings and the impact of radiotherapy in PBR. CharacteristicNumber of patients or proceduresTotal number of procedures1020Procedures with adjuvant radiation therapy166 (16.27)Age (years)49BMI (kg/m2)25Management of axilla Axillary nodal clearance56 (33.73)Type of reconstructionOne-stage128 (77.11)Two-stage22 (13.25)Missing16 (9.64)Hospital stay (days)1 (0-10)Breast specimen weight (grams)452 (108-1578)Implant size (cc)400 (130-700)Adjuvant chemotherapy93 (56.02) Citation Format: Mihir Chandarana, Sankaran Narayanan, Rishikesh Parmeshwar. Pre-pectoral implant-based reconstruction and adjuvant radiation therapy - Surgical outcomes from a multicentre study in United Kingdom [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-23.

Deep Surgical-Site Infection Following Thoracolumbar Instrumented Spinal Surgery: The Experience of 25 Years.

Deep surgical-site infection following thoracolumbar instrumented spinal surgery (DSITIS) is a major complication in spine surgery and its impact on long-term morbidity and mortality is yet to be determined. This article describes the characteristics and evolution of DSITIS in our center over a period of 25 years. This single-center, retrospective cohort study included patients diagnosed with DSITIS between January 1992 and December 2016 and with a minimum follow-up after infection diagnosis of 1 year. The Infectious Diseases Society of America criteria and/or Centers for Disease Control and Prevention criteria were used to define DSITIS. Patient data (epidemiological and health status), surgical data, infection characteristics and presentation, isolated microorganisms, required surgical debridements, implant removal, and major complications linked to infection were evaluated. A total of 174 patients (106 females) were included in the analysis. Mean follow-up after infection diagnosis was 40 months (56 patients with over 5 years follow-up). Adolescent idiopathic scoliosis, adult deformity, and degenerative lumbar stenosis were the most frequent etiologies for primary surgery. Presentation of infection was considered early (0-3 months since first surgery) in 59.2% of the cases, delayed (3-24 months) in 11.5%, and late (more than 24 months) in 29.3%. All patients were treated by surgical debridement. More than 1 surgical debridement was necessary in 20.7% of cases. Implants were removed in 46.6% of the patients (72.83% in the first surgical debridement). Most frequently isolated microorganisms were Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes. Major complications appeared in 14.3% of the patients, and over 80% of them required major surgeries to resolve those complications. Late DSITIS is more frequent than previously reported. In DSITIS culprits, Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes predominate. DSITIS produce a high rate of major complications that usually require major surgery for treatment. 3.

Complications using tissue expanders in burn sequelae treatment at a reference university hospital: a retrospective study.

tissue expanders have high relevance in plastic surgery and among indications it is worth mentioning their use in the treatment of burn reconstruction. Although it shows good results, its use requires special care because some complications can interrupt the reconstruction process. The objective of this study was to report the experience of the Clinics Hospital (University of Sao Paulo) with the use of tissue expanders to treat burn sequelae, establishing the incidence of complications, and identifying risk factors for their occurrence. a retrospective, observational, and analytical study, evaluating the use of expanders in burns sequelae treatment from 2009 to 2018. 245 expanders were placed in 84 patients, 215 were female, with a mean age of 19.96 years, being 40% in the trunk and 20% in the scalp, with a predominance of rectangular shape in 76.7% of cases. Complications were classified as major and minor.Complications occurred in 17.95% of cases, and extrusion and infection were the most common. There was a higher incidence of complications in expanders used in the upper and lower limbs as well as in those who did not undergo concomitant expansion (p <0.05), with an even higher chance of major complications in patients submitted to additional expansion. From 2009 to 2018, we observed a decrease in the incidence of complications. the complication rate (17.95%) is similar to other studies of the literature, there was a higher rate of complication with expanders placed in the limbs and a higher rate of major complications when additional expansion was done.

Transvenous extraction of permanent pacemaker and defibrillator leads: Reduced procedural complexity and higher procedural success rates in patients with infective versus noninfective indications.

Transvenous lead extraction (TLE) is critical in the long-term management of patients with cardiac implanted electronic devices (CIEDs). The aim of the study is to evaluate the outcomes of TLE and to investigate the impact of infection. Data of patients undergoing extraction of permanent pacemaker and defibrillator leads during October 2014-September 2019 were prospectively analyzed. Overall, 242 consecutive patients (aged 71.0 ± 14.0 years, 31.4% female), underwent an equal number of TLE operations for the removal of 516 leads. Infection was the commonest indication (n = 201, 83.1%). Mean implant-to-extraction duration was 7.6 ± 5.4 years. Complete procedural success was recorded in 96.1%, and clinical procedural success was achieved in 97.1% of attempted lead extractions. Major complications occurred in two (0.8%) and minor complications in seven (2.9%) patients. Leads were removed exclusively by using locking stylets in 65.7% of the cases. In the subgroup of noninfective patients, advanced extraction tools were more frequently required compared to patients with CIED infections, to extract leads (success only with locking stylet: 55.8% vs. 67.8%, p = .032). In addition, patients without infection demonstrated lower complete procedural success rates (90.7% vs. 97.2%, p = .004), higher major complication rates (2.4% vs. 0.5%, p = .31) and longer procedural times (136 ± 13 vs. 111 ± 15 min, p = .001). Our data demonstrate high procedural efficacy and safety and indicate that in patients with noninfective indications, the procedure is more demanding, thus supporting the hypothesis that leads infection dissolves and/or prohibits the formation of fibrotic adherences.

Thoracofemoral bypass outcomes in the Vascular Quality Initiative

ObjectiveThoracofemoral bypass (TFB) has been used infrequently but is an alternative for select patients with aortoiliac occlusive disease. Limited data are available in the reported data regarding TFB, with all studies small, single-center series. We aimed to describe the perioperative and long-term survival, patency, and rate of major perioperative complications after TFB in a large national registry. MethodsThe Vascular Quality Initiative suprainguinal bypass module was used to identify patients who had undergone TFB for occlusive disease from 2009 to 2019. A descriptive analysis was performed to provide the rates of survival, patency, major complications, and freedom from major amputation in the perioperative period and at 1 year of follow-up. Major complications were compared by procedure indication, with categorical variables analyzed using χ2 tests and continuous variables using analysis of variance. Kaplan-Meier curve analysis was used to estimate survival at the 1- and 5-year follow-up intervals and freedom from major amputation at 1 year. ResultsA total of 154 TFB procedures were identified. Of the 154 patients, 59 (38.3%) had undergone previous inflow bypass and 22 (14.2%) had undergone previous leg bypass. The procedure indications included claudication (n = 66; 42.9%), rest pain (n = 59; 38.3%), tissue loss (n = 19; 12.3%), and acute limb ischemia (n = 10; 6.5%). Major complications (eg, wound infection, respiratory, major stroke, new dialysis, cardiac, embolic, major amputation, occlusion) occurred in 31.2% of the cohort. When examined by indication, the acute limb ischemia and claudication cohorts had an increased rate of major complications (acute limb ischemia, 60.0%; claudication, 34.8%; critical limb ischemia, 24.4%; P = .05). The survival rate at 30 days was 95.5%, with a Kaplan-Meier estimated 1-year survival rate of 92.7% ± 2.2%. Primary patency at discharge from the index hospitalization was 92.9% and 89.0% at 1 year. Postoperative major amputation was required for 1 patient during the index hospitalization, for a Kaplan-Meier estimated freedom from major amputation at 1 year of 97.1% ± 2.2%. Two patients developed in-hospital bypass occlusion and three patients developed occlusion within 1 year, for an overall freedom from occlusion rate of 96.8% at 1 year. ConclusionsTFB is associated with a high rate of perioperative major complications; however, the long-term survival and patency after TFB remained acceptable when performed for limb salvage. The high perioperative complication rates of TFB procedures performed for claudication suggest TFB should be used rarely in this population. These data can be used to counsel patients and aid in decision making before operative intervention.

Comparison of Cochlear Implant Device Fixation-Well Drilling Versus Subperiosteal Pocket. A Cost Effectiveness, Case-Control Study.

To compare surgical characteristics and complications between well drilling (WD) and subperiosteal pocket techniques (SPT) for receiver/stimulator (R/S) fixation of cochlear implant (CI), and conduct cost-effectiveness analysis. Retrospective clinical study, decision-analysis model. Tertiary referral center. Three-hundred and eighty-eight CI recipients with a minimum of 6-months follow-up. CI surgery using either WD or SPT for R/S fixation. A decision-analysis model was designed using data from a systematic literature review. Surgical operation time, rates of major and minor long-term complications were compared. Incremental cost-effectiveness was also estimated, comparing the two methods of fixation. We compared 179 WD with 209 SPT. Surgery time was significantly shorter in SPT (148 versus 169 min, p = 0.001) and remained significant after adjustment for possible confounders. Higher rates of major complications requiring surgical intervention were found with SPT (10.5% versus 4.5%, p = 0.042), however, the difference was not significant after adjusting for follow-up time (47.8 versus 32.5 months for SPT, WD respectively; p < 0.001). The incremental cost-effectiveness ratio for WD (compared with SPT) was $48,795 per major complication avoided, which was higher than the willingness-to-pay threshold of $47,700 (average cost of 2 h revision surgery). SPT was found to be faster but potentially risks more complications, particularly relating to device failure. Further long-term studies are required to validate these differences. Based on data from the current literature, neither of the methods is compellingly cost-effective over the other, and surgeons can base their choice on personal preference, comfort, and previous training.

Angioplasty versus stenting for iliac artery lesions

Angioplasty versus stenting for iliac artery lesions

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction.

BackgroundDespite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality.Study DesignThe NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications.ResultsOf 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01).ConclusionsImmediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Robotic versus open oncological gastric surgery in the elderly: a propensity score-matched analysis

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥ 65 or 75 years is used. Even if robot-assisted surgery is a validated option for the elderly population, there are no specific indications for its application in the surgical treatment of gastric cancer. The aim of this study is to evaluate the safety and feasibility of robot-assisted gastrectomy and to compare the short and long-term outcomes of robot-assisted (RG) versus open gastrectomy (OG). Patients aged ≥ 70 years old undergoing surgery for gastric cancer at the Department of Surgery of San Donato Hospital in Arezzo, between September 2012 and March 2017 were enrolled. A 1:1 propensity score matching was performed according to the following variables: age, Sex, BMI, ASA score, comorbidity, T stage and type of resection performed. 43 OG were matched to 43 RG. The mean operative time was significantly longer in the RG group (273.8 vs. 193.5 min, p < 0.01). No differences were observed in terms of intraoperative blood loss, an average number of lymph nodes removed, mean hospital stay, morbidity and mortality. OG had higher rate of major complications (6.9 vs. 16.3%, OR 2.592, 95% CI 0.623–10.785, p = 0.313) and a significantly higher postoperative pain (0.95 vs. 1.24, p = 0.042). Overall survival (p = 0.263) and disease-free survival (p = 0.474) were comparable between groups. Robotic-assisted surgery for oncological gastrectomy in elderly patients is safe and effective showing non-inferiority comparing to the open technique in terms of perioperative outcomes and overall 5-year survival.

Agitation and delirium in intensive cardiac care unit. A multicenter prospective registry

Abstract Background Patients with acute cardiovascular disease admitted to the Intensive Cardiac Care Unit (ICCU), especially those with more severe critical illness, experiment agitation and delirium during hospitalization. Iatrogenic, environmental, or related to the severity of acute illness factors may concur to determine these two conditions. However, their epidemiological, clinical, and prognostic relevance in this specific clinical context are not well defined, yet. As a result, current recommendations on the evaluation and management of these complications are lacking. The aim of this prospective, multicenter, observational registry was to evaluate the incidence of agitation and delirium in patients admitted to the ICCU for an acute cardiac event, their in-hospital prognostic impact, and their treatment. Methods We enrolled consecutive patients with acute cardiovascular events in four Italian tertiary-care centers. Agitation levels were ranked from Richmond Assessment Sedation Scale (RASS), and the presence of delirium was detected by Confusion Assessment Method-Intensive Care Unit (CAM ICU) at least twice a day and in case of variation of the state of consciousness. The primary endpoint was the incidence of agitation and/or delirium. The secondary endpoints were: 1) the association between these complications and in-hospital outcome and 2) the therapies adopted for their management. Results Overall, 723 patients were included in the registry. Of them, 116 (16%) presented agitation and/or delirium during ICCU stay. Delirium subtypes were: 6% hypoactive, 64% hyperactive, and 30% mixed. Patients with agitation/delirium had worse in-hospital outcomes than patients without.. Indeed, they had a higher ICCU mortality (10% vs. 2%; P&amp;lt;0.001) and a higher rate of major complications: ventricular arrhythmias (26% vs. 12%; P&amp;lt;0.001), atrial fibrillation (29% vs. 15%; P&amp;lt;0.001), sepsis (15% vs. 9%; P=0.06), and bleeding (17% vs. 7%; P&amp;lt;0.001). Moreover, they were more frequently treated with mechanical procedures: invasive and non-invasive ventilation (58% vs. 18%; P&amp;lt;0.001), circulatory support (20% vs. 5%; P&amp;lt;0.001), continuous renal replacement therapy (6% vs. 1%; P&amp;lt;0.001). Finally, ICCU length of stay was longer (8 vs. 4 days; P&amp;lt;0.001). The drugs more likely used for agitation treatment were benzodiazepine (32%), dexmedetomidine (31%), opioids (10%), and antipsycotic drugs (1%). Delirium was mainly treated with dexmedetomidine (46%), benzodiazepine (23%), antipsycotic drugs (16%), and opioids (8%). Conclusions This study demonstrates that agitation and delirium are frequent complications also in the acute cardiac setting and are associated with poor in-hospital outcome. In this particular context, the treatment of choice and its possible impact on prognosis remain to be established. Funding Acknowledgement Type of funding source: Private hospital(s). Main funding source(s): Centro Cardiologico Monzino, IRCCS, MIlan, Italy.

Incidence of immediate postextubation complications in critically Ill adult patients

BackgroundPostextubation complication rates vary among studies. It is necessary to standardize a method to identify postextubation complications and determine their potential association with extubation failure and reintubation in critically ill adult patients. ObjectivesTo describe immediate (up to 60 min) endotracheal postextubation complications in critically ill adult patients and determine whether these complications are associated with extubation failure. MethodsSecondary analysis of a Randomized Clinical Trial that included 240 critically ill adult patients, who were eligible for extubation. Overall complications include at least one major complication (upper airway obstruction, desaturation, vomiting, post-obstructive pulmonary edema) and/or minor complications (bronchospasm, severe cough, hypertension, tachycardia, tachypnea, poor respiratory mechanics). ResultsIncidence of overall, major and minor complications was 71.2%, 30.9% and 62.7%, respectively. Forty (16.9%) patients failed extubation, and thirty (12.7%) were reintubated. Of 168 patients who developed a postextubation complication, 137 (81.5%) were successfully extubated. Only major complications were significantly associated with reintubation after extubation failure (p<0.001). ConclusionWe have observed high incidence rates of overall, major and minor complications. The development of major complications was statistically significantly associated with extubation failure and reintubation. It is still unknown whether the identification and treatment of immediate postextubation complications have positive effects on patients' clinical course or whether the complications are a mere effect of the extubation procedure.

Early fixation of traumatic spinal fractures and the reduction of complications in the absence of neurological injury: a retrospective cohort study from the American College of Surgeons Trauma Quality Improvement Program.

The optimal timing of operative stabilization of patients with traumatic spinal fractures without spinal cord injury (SCI) has not been established. The challenges of early operative intervention, which may require prone positioning in a patient with multisystem injuries, must be balanced with the disadvantages of prolonged immobilization. The authors set out to define the optimal timing of surgical repair of traumatic spinal fractures in patients without SCI and the effect of delayed repair on the incidence of major complications. A retrospective cohort study was conducted using data derived from the American College of Surgeons Trauma Quality Improvement Program. Adult trauma patients who underwent operative fixation of a spinal fracture within 7 days of admission were included. Patients with SCI were excluded. The primary outcome was the occurrence of a major complication. Secondary outcomes included death and length of stay. Restricted cubic splines were used to model the nonlinear effects of time to spinal fixation and determine a threshold beyond which stabilization was associated with a higher rate of major complications. Logistic regression and propensity score matching were then used to derive estimates for the association between delayed fixation and major complications. The authors identified 19,310 patients treated at 389 centers who met the inclusion criteria. Modeling identified fixation beyond 24 hours as a risk for major complications. Adjusting for potential confounders using multivariable logistic regression showed that late fixation was associated with a 1.30 (95% CI 1.15-1.46) times increased odds of developing a major complication. After propensity score matching, late fixation remained associated with a 1.25 (95% CI 1.13-1.39) times increased risk of experiencing a major complication. In the absence of clear contraindications, surgeons should strive to stabilize traumatic spinal fractures without SCI within 24 hours. Early fixation can be expected to reduce major complications by 25%-30%.

Oxaliplatin versus mitomycin C in HIPEC for peritoneal metastasis from colorectal cancer: a systematic review and meta-analysis of comparative studies.

Hyperthermic intraperitoneal perfusion chemotherapy (HIPEC) following cytoreductive surgery (CRS) has been applied for peritoneal metastasis (PM) from colorectal cancer (CRC). This study aimed to compare oxaliplatin (OX) with mitomycin C (MMC) in HIPEC for PM from CRC in surgical and survival outcomes. A systematic literature search was performed in PubMed and Ovid databases for studies comparing OX with MMC in HIPEC for PM from CRC. The last search was performed on June 21, 2020. Eleven articles published between 2006 and 2020 with 2091 patients were included. When compared with MMC group, the OX group showed significantly higher rate of major complications (P = 0.006, OR = 1.57, 95% CI [1.14, 2.16], I2 = 0%). Besides, no significant difference was observed between the two groups for survival outcomes, regardless of 3-year overall survival (P = 0.98, OR = 1.00, 95% CI [0.83, 1.22], I2 = 0%), 3-year disease-free survival (P = 0.98, OR = 1.00, 95% CI [0.83, 1.22], I2 = 0%), or 5-year overall survival (P = 0.91, OR = 1.01, 95% CI [0.81, 1.26], I2 = 0%). OX and MMC could achieve comparable survival in HIPEC for PM from CRC. However, in consideration of the high incidence of major complication in OX group, MMC might be the safer one in clinical routines.

Comparison of Outcomes of Coronary Revascularization for Acute Myocardial Infarction in Men Versus Women

This study sought to examine the differences in the characteristics and outcomes between men and women who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) in contemporary US practice. The Nationwide Inpatient Sample was used to identify patients who underwent revascularization for AMI between January 1, 2003 and December 31, 2016. The primary outcome was in-hospital mortality. Propensity score matching was utilized to account for differences in baseline characteristics. In total, 3,603,142 patients were included, of whom only 1,180,436 (33%) were women. Compared with men, women were older and had higher prevalence of key co-morbidities including diabetes, hypertension, congestive heart failure, and chronic kidney and lung disease (p <0.001). In the PCI cohort, women were significantly less likely to undergo multivessel PCI, to receive mechanical circulatory support, or to undergo atherectomy. In the CABG group, women were more likely to have concomitant valve surgery. In the propensity-matched cohorts, in-hospital mortality was higher for women than men regardless of revascularization strategy: 7.6% versus 6.6% for PCI in ST-elevation myocardial infarction, 2.0% versus 1.9% for PCI in non-ST-elevation myocardial infarction, and 5.7% versus 4.3% for CABG in any AMI (p <0.001). Women also had higher rates of major complications, longer hospitalizations, higher costs, and were less likely to be discharged home (vs nursing facility). These sex-based differences persisted over the study 14-year period. In conclusion, in a contemporary nationwide analysis of propensity score-matched patients, women who undergo revascularization for AMI have worse in-hospital outcomes than men regardless of revascularization mode.

Outcomes of Bariatric Surgery in African Americans: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Data Registry.

BackgroundThe incidence of obesity is disproportionally high in African Americans (AA) in the United States. This study compared outcomes for AA patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with non-AA patients.MethodsThe MBSAQIP database was reviewed for RYGB and SG patients (2015–2017). Patients were identified as AA or non-AA and grouped to RYGB or SG. Combined and univariate analyses were performed on unmatched/propensity matched populations to assess outcomes.ResultsAfter applying exclusion criteria, 75,409 AA and 354,305 non-AA patients remained. Univariate analysis identified AA-RYGB and AA-SG patients were heavier and younger than non-AA patients. Overall, AA patients tended to have fewer preoperative comorbidities than non-AA patients with the majority of AA comorbidities related to hypertension and renal disease. Analysis of propensity matched data confirmed AA bariatric surgery patients had increased cardiovascular-related disease incidence compared with non-AA patients. Perioperatively, AA-RYGB patients had longer operative times, increased rates of major complications/ICU admission, and increased incidence of 30-day readmission, re-intervention, and reoperation, concomitant with lower rates of minor complications/superficial surgical site infection (SSI) compared with non-AA patients. For SG, AA patients had longer operative times and higher rates of major complications and 30-day readmission, re-intervention, and mortality, coupled with fewer minor complications, superficial/organ space SSI, and leak.ConclusionAfrican American patients undergoing bariatric surgery are younger and heavier than non-AA patients and present with different comorbidity profiles. Overall, AAs exhibit worse outcomes following RYGB or SG than non-AA patients, including increased mortality rates in AA-SG patients.

Total Psoas Area Index is Valuable to Assess Sarcopenia, Sarcopenic Overweight/Obesity and Predict Outcomes in Patients Undergoing Open Pancreatoduodenectomy.

Background and AimSarcopenia has been proven to be a risk factor after pancreatoduodenectomy (PD). We aimed to evaluate if decreased psoas muscle area and density shown in CT scan, as measures for sarcopenia, were associated with postoperative major complications and adverse outcomes in patients who underwent PD.Patients and MethodsWe analyzed 152 consecutive patients who underwent open PD. Total psoas area and muscle attenuation were measured on CT images at the level of the third lumbar vertebra. Total psoas area index (TPAI) was calculated, the cut-off values of TPAI were estimated and validated. The relationship between radiographic characters and outcomes was analyzed.ResultsThe optimal cut-off values of TPAI were 4.78 cm2/m2 for males and 3.46 cm2/m2 for females. The values were validated by outcomes with significant differences in the rate of major complications, re-operation, length of stay, and total cost. The prevalence of TPAI-defined sarcopenia and sarcopenic overweight/obesity was 38.8% and 17.1% in total. In multivariate logistic regression, rate of major complications was associated with TPAI [OR=0.605, 95% CI (0.414, 0.883), P=0.009], TPAI-defined sarcopenia [OR=8.256, 95% CI (2.890, 23.583), P=0.000] and sarcopenic overweight/obesity [OR=7.462, 95% CI (2.084, 26.724), P=0.002]; meanwhile, NRS2002-defined nutritional risk and GLIM-defined malnutrition did not show relationship with major complications.ConclusionBoth sarcopenia and sarcopenic overweight/obesity determined by new TPAI cut-off values were associated with a higher rate of major complications and adverse outcomes in Chinese patients undergoing open PD whereas usual nutritional assessment was not.

Jejunostomy Tube Insertion for Enteral Nutrition: Comparison of Outcomes after Laparoscopic versus Radiologic Insertion

PurposeTo retrospectively compare technical success and major complication rates of laparoscopically versus radiologically inserted jejunostomy tubes. Materials and MethodsIn this single-institution retrospective study, 115 patients (60 men; mean age, 59.7 y) underwent attempted laparoscopic jejunostomy tube insertion as a standalone procedure during a 10-year period and 106 patients (64 men; mean age, 61.0 y) underwent attempted direct percutaneous radiologic jejunostomy tube insertion during an overlapping 6-year period. Clinical outcomes were retrospectively reviewed with primary focus on predictors of procedure-related major complications within 30 days. ResultsPatients undergoing laparoscopic jejunostomy tube insertion were less likely to have previous major abdominal surgery (P < .001) or to be critically ill (P < .001) and had a higher body mass index (P = .001) than patients undergoing radiologic insertion. Technical success rates were 95% (110 of 115) for laparoscopic and 97% (103 of 106) for radiologic jejunostomy tube insertion (P = .72). Major procedural complications occurred in 7 patients (6%) in the laparoscopic group and in 5 (5%) in the radiologic group (P = 1.0). For laparoscopic jejunostomy tubes, only previous major abdominal surgery was significantly associated with a higher major procedure complication rate (14% [5 of 37] vs 3% [2 of 78] in those without; P = .039). In the radiologic jejunostomy group, only obesity was significantly associated with a higher major complication rate: 20% (2 of 10) vs 3% (3 of 96) in nonobese patients (P = .038). ConclusionsLaparoscopic and radiologic jejunostomy tube insertion both showed high success and low complication rates. Previous major abdominal surgery and obesity may be pertinent discriminators for patient selection.

Long-term follow-up of abandoned transvenous defibrillator leads: a nationwide cohort study.

Commonly, a dysfunctional defibrillator lead is abandoned and a new lead is implanted. Long-term follow-up data on abandoned leads are sparse. We aimed to investigate the incidence and reasons for extraction of abandoned defibrillator leads in a nationwide cohort and to describe extraction procedure-related complications. All abandoned transvenous defibrillator leads were identified in the Danish Pacemaker and ICD Register from 1991 to 2019. The event-free survival of abandoned defibrillator leads was studied, and medical records of patients with interventions on abandoned defibrillator leads were audited for procedure-related data. We identified 740 abandoned defibrillator leads. Meantime from implantation to abandonment was 7.2 ± 3.8 years with mean patient age at abandonment of 66.5 ± 13.7 years. During a mean follow-up after abandonment of 4.4 ± 3.1 years, 65 (8.8%) abandoned defibrillator leads were extracted. Most frequent reason for extraction was infection (pocket and systemic) in 41 (63%) patients. Procedural outcome after lead extraction was clinical success in 63 (97%) patients. Minor complications occurred in 3 (5%) patients, and major complications in 1 (2%) patient. No patient died from complication to the procedure during 30-day follow-up after extraction. More than 90% of abandoned defibrillator leads do not need to be extracted during long-term follow-up. The most common indication for extraction is infection. Abandoned defibrillator leads can be extracted with high clinical success rate and low risk of major complications at high-volume centres.

The Intersection of Age and Tumor Biology with Postoperative Outcomes in Patients After Cytoreductive Surgery and HIPEC.

Patient age is a significant factor in preoperative selection for major abdominal surgery. The association of age, tumor biology, and postoperative outcomes in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains ill-defined. Retrospective analysis was performed for patients who underwent a CCR0/1 CRS/HIPEC from the US HIPEC Collaborative Database (2000-2017). Age was categorized into < 65 or ≥ 65years. Primary outcome was postoperative major complications. Secondary outcomes were non-home discharge (NHD) and readmission. Analysis was stratified by disease histology: non-invasive (appendiceal LAMN/HAMN), and invasive (appendiceal/colorectal adenocarcinoma). Of 1090 patients identified, 22% were ≥ 65 (n = 240), 59% were female (n = 646), 25% had non-invasive (n = 276) and 51% had invasive (n = 555) histology. Median PCI was 13 (IQR 7-20). Patients ≥ 65 had a higher rate of major complications (37 vs 26%, p = 0.02), NHD (12 vs 5%, p < 0.01), and readmission (28 vs 22%, p = 0.05), compared to those < 65. For non-invasive histology, age ≥ 65 was not associated with major complications or NHD on multivariable analysis. For invasive histology, when accounting for PCI and CCR, age ≥ 65 was associated with major complications (OR 2.04, 95% CI 1.16-3.59, p = 0.01). When accounting for major complications, age ≥ 65 was associated with NHD (OR 2.54, 95% CI 1.08-5.98, p = 0.03). Age ≥ 65 was not predictive of readmission for any histology when accounting for major complications. Age ≥ 65years is an independent predictor for postoperative major complications and non-home discharge for invasive histology, but not non-invasive histology. These data inform preoperative counseling, risk stratification, and early discharge planning.