High-volume Surgeons Research Articles

The Association Between Operative Times and Outcomes in Complex Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Endovascular aortic repairs of aneurysms involving the thoracoabdominal aorta (eTAAA) are becoming increasingly common. However, there are no commercially available grafts in the United States for these repairs, and as a result, experience and repair methods vary widely and data are limited. We therefore sought to explore the impact of operative time on perioperative outcomes following eTAAA. We studied all eTAAA repairs (Crawford types 1-3) from 2014 to 2021 in the Vascular Quality Improvement database, and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a subanalysis stratifying each surgeon by their median operating time. Multilevel logistic regression was employed to compare perioperative outcomes. We identified 921 complex endovascular thoraco-abdominal aortic repairs. Operating times ranged from <204 minutes in quartile 1 (Q1), to >360 minutes in Q4. Patient demographics, procedural urgency, and aneurysm extent were similar across quartiles. However, repairs in the first quartile were more often staged procedures, with fewer target vessels incorporated, lower usage of spinal drains, and less often utilized parallel grafts or upper extremity access. High volume surgeons and high volume hospitals were more likely to have lower procedure times. In adjusted analysis, procedures in Q3 (270-360 minutes) were associated with double the odds of almost every major perioperative outcome compared to Q1, and Q4 was associated with 3- to 8-fold higher odds. This included mortality (Q3: odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.8; P = .5; Q4: OR, 4.2; 95% CI, 2.1-8.5; P < .001), thoracoabdominal life-altering events (a composite of perioperative death, stroke, permanent paralysis and dialysis) (Q3: OR, 2.2; 95% CI, 1.1-4.1; P = .02; Q4: OR, 8.0; 95% CI, 4.3-15.0; P < .001), spinal cord ischemia (Q3: OR, 2.4; 95% CI, 1.02-5.6; P = .045; Q4: OR, 5.2; 95% CI, 2.3-11.6; P < .001), and acute kidney injury (Q3: OR, 2.2; 95% CI, 1.2-4.0; P = .009; Q4: OR, 5.0; 95% CI, 2.8-8.9; P < .001). Similar trends were seen for rates of major adverse cardiac events, myocardial infarction, and need for dialysis (Table, Figure). Results were consistent when surgeons were analyzed by median procedure time, as surgeons who ranked in the fourth quartile were associated with higher odds of perioperative death, thoracoabdominal life-altering events, major adverse cardiac events, and acute kidney injury. In this study, longer operative time in eTAAA was associated with a higher risk of adverse perioperative outcomes. These results suggest that expeditious repairs, with a focus on avoiding prolonged renal/visceral, pelvic and leg ischemia, are important in achieving optimal results in these challenging repairs, and suggest that strategies such as staged repairs may improve outcomes by decreasing procedure times.TableOdds ratios for perioperative outcomes based on operating time.First quartile (<204 minutes)Second quartile (205-269 minutes)P valueThird quartile (270-360 minutes)P valueFourth quartile (>360 minutes)P valueMortalityRef0.6 [0.2-1.5J0.271.3 [0.6 -2.8]0.454.2 [2.1-8.5]<.001TALERef1.6 [0.8-3.110.22.2 [1.1-4.110.0218.0 [4.3-15.01<.001StrokeRef2.5 [0.4-14.610.321.6 [0.3 -9.7]0.613.6 [0.6-20.2[.15MIRef0.8 [0.2 – 2.9]0.773.7 [1.3 -10.3]0.0143.1 [1.1-8.9].032MACERef1.2 [0.6-2.3)0.581.9 [1.03 – 3.5]0.0384.8 [2.7-8.76]<.001AKIRef0.9 [0.5-1.810.762.2 [1.2 -4.0]0.0095.0 f2.8-8.91<.001SCIRef1.6 [0.6-3.9)0.312.4 [1.02 – 5.5]0.0455.2 [2.3-11.6]<.001Permanent SCIRef1.6 [0.5-5.8]0.452.6 [0.8-8.5]0.116.3 [2.0-19.6].001DialysisRef0.9 [0.2-3.9J0.932.2 [0.6 -7.8]0.215.8 [1.8-18.51.003AKI, Acute kidney injury; MACE, major adverse cardiac event; MI, myocardial infarction; SCI, spinal cord ischemia.Values are adjusted by total operating time. Open table in a new tab

Outcomes Following Fenestrated Endovascular Aortic Repair for Failed Infrarenal Endovascular Aortic Repair Compared With Primary Fenestrated Endovascular Aortic Repair

Fenestrated endovascular aortic repair (FEVAR) is a potential treatment option in patients with failed EVAR due to proximal disease progression. However, studies evaluating the outcomes after FEVAR in patients with prior EVAR are limited to data from single-center and high-volume institutions. Therefore, we compared the outcomes after FEVAR in patients with prior EVAR vs without any prior aortic surgery (primary FEVAR). We identified patients undergoing elective FEVAR for complex abdominal aortic aneurysm in the Vascular Quality Initiative between 2014 and 2022 and included those who underwent no prior aortic surgery (n = 2362) or prior EVAR (n = 117). Perioperative outcomes and 5-year mortality were analyzed using logistic regression and Cox regression models. Sac changes were assessed based on differences in aneurysm sac diameter between the 1-year computed tomography scan and preoperative imaging and were categorized as regression (>5 mm decrease), stability (<5 mm change in size), and expansion (>5 mm increase) for analysis. We included 2362 primary FEVAR patients and 117 patients who underwent FEVAR after EVAR. The FEVAR after EVAR patients were older (76 [72-82] years vs 74 [68-79] years; P < .001), less frequently female (12% vs 23%; P = .004), had larger aneurysm diameters (68 [60-80] mm vs 58 [55-63] mm; P < .001), and more preoperative comorbidities. After EVAR patients, FEVAR patients were more likely to undergo repairs at high-volume centers performed by high-volume surgeons (P < .001). Furthermore, FEVAR after EVAR involved more proximal aortic zones with a higher number of branches and longer procedural time and radiation (all P < .05). Despite these differences, FEVAR after EVAR showed comparable perioperative outcomes relative to primary FEVAR (Table I). However, in the FEVAR, after EVAR group, 1-year sac regression rates were lower (24% vs 51%; P = .005), whereas sac expansion was more likely (39% vs 7.3%; P < .001) compared with the primary FEVAR group (Table II). At 2-year follow-up, FEVAR after EVAR was associated with similar mortality (26% vs 19%; hazard ratio: 1.4, 95% confidence interval: 0.84-2.2; P = .20) and reinterventions (14% vs 13%; hazard ratio: 1.04, 95% confidence interval: 0.36-3.0; P = .91) compared with primary FEVAR. FEVAR after EVAR has a similar risk of perioperative and 2-year mortality compared with primary FEVAR. However, the higher rate of sac expansion at 1 year in these patients raises significant concerns about the durability of these repairs. Therefore, patients undergoing FEVAR after EVAR may benefit from closer surveillance or even consideration for open conversion. Future studies should evaluate open conversion as an alternative to endovascular treatment for proximal failure of EVAR.Table IPerioperative outcomes after primary FEVAR vs FEVAR after prior EVARPrimary FEVAR (n = 2373)FEVAR after EVAR (n = 130)P valueFEAVR after EVAR vs primary FEVARP valueUnadjusted rates, %Adjusteda OR [95% CI]Perioperative death2.82.3.800.62 [0.13-2.2].50Any complication9.611.770.65 [0.29-1.4].30 Stroke0.60.66NANA AKI1214.700.75 [0.38-1.4].4 Postoperative dialysis1.72.3.740.73 [0.10-3.28].71 Bowel ischemia1.91.51.01.4 [0.18-6.2].71 Spinal cord ischemia1.53.1.270.85 [0.11-4.0].85 Leg ischemia1.92.3.740.68 [0.10-3.0].65 Pulmonary complications3.64.6.620.70 [0.21-2.0].52 Cardiac complications3.53.81.00.53 [0.14-1.6].30 Completion type 1A endoleak3.40.8.120.32 [0.02-1.73].29Reintervention during index hospitalization4.26.2.380.73 [0.48-1.1].12Unadjusted rates, %P valueAdjusteda HR [95% CI]P value2-year reintervention1314.201.04 [0.36-3.0].912-year mortality1926.701.4 [0.84-2.2].20AKI, Acute kidney injury; CI, confidence interval; EVAR, endovascular aortic repair; FEVAR, fenestrated EVAR; HR, hazard ratio; OR, odds ratio.aAdjusted for age, gender, diameter (>65 mm), hypertension, diabetes, prior myocardial infarction, prior chronic obstructive pulmonary disease, obesity, prior chronic kidney disease, anemia, proximal sealing zone, center volume, and physician volume. Open table in a new tab Table IISac dynamics at 1 year after primary FEVAR vs FEVAR after prior EVARPrimary FEVAR (n = 853), %FEVAR after EVAR (n = 33), %P valueSac regression, >5 mm5124.005Stable sac, <5 mm4232.67Sac expansion, >5 mm7.339<.001EVAR, Endovascular aortic repair; FEVAR, fenestrated EVAR.Boldface P value represents significance P < .05. Open table in a new tab

Perioperative Outcomes After Carotid Revascularization in Asian Patients Varies With Asian Procedure Density

The nature of postoperative outcomes following carotid revascularization is understudied in Asian patients. We aimed to determine if there are disparities in disease severity and postoperative outcomes in Asian patients following carotid revascularization and whether this varies with procedure frequency in Asian patients. We analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy and Carotid Artery Stenting datasets from 2003 to 2021. We divided regions into tertiles based on Asian procedure density. Propensity scores were used to match White and Asian patients based on age, sex, comorbidities, contralateral carotid occlusion, and procedure type. Logistic and Cox regressions were performed within the matched cohort. The primary outcome variable was in-hospital ipsilateral stroke/death/myocardial infarction and we also examined differences in disease severity, center and surgeon volume, and late outcomes. A total of 159,608 White and 1766 Asian patients underwent carotid revascularization and we identified 2704 patients in the matched cohort. On adjusted analysis, there was no difference in symptomatic disease rate between groups (35%). However, Asian patients more commonly presented with >80% ipsilateral stenosis (63% vs 52%; P < .001) and a moderate/severe preoperative Rankin score (7.6% vs 5.1%; P = .007), which did not vary with Asian procedure density. The rate of in-hospital stroke/death/myocardial infarction was higher in Asian patients (2.6% vs 1.3%; P = .012), and this disparity was more pronounced in the lowest tertile of Asian procedure density (4.3% vs 0.5%; P < .001). Logistic regression within the propensity-matched cohort demonstrated Asian race was associated with a decreased odds of care by highest volume centers and surgeons, which was largely consistent across tertiles of Asian procedure density (Table I). Asian race was associated with twofold greater odds of in-hospital stroke/death/myocardial infarction, which was driven by the lowest tertile regions of Asian procedure density. After clustering at surgeon and center level, the effect of Asian race was mitigated. Cox regression within the matched cohort demonstrated that Asian race was protective against late mortality, with no differences in 1-year stroke or reintervention-free survival (Table II). Asian patients are more likely to present with a greater degree of carotid stenosis, preoperative risk, and experience worse perioperative outcomes. The increased odds of perioperative stroke/death/myocardial infarction is driven by regions with low Asian procedure density and is also mediated by the volume of centers and surgeons with which Asian patients tend to undergo care. These results highlight the need to understand the social and cultural effects on outcomes disparities in Asian patients.Table ILogistical regression of outcomes in propensity-matched cohortAssociation With Asian RaceOR (95% CI; P)ORa (95% CI; P)In-hospital stroke/death/myocardial infarction2.1 (1.2-3.7; P = .014)1.4 (0.7-3.0; P = .354)Operation at highest volume centers0.2 (0.2-0.3; P < .001)--Operation with highest volume surgeons0.3 (0.3-0.4; P < .001)--CI, Confidence interval; OR, odds ratio.aLogistical regression with clustering at surgeon and center level. Open table in a new tab Table IICox regression of late outcomes in propensity-matched cohortAsian RaceHR (95% CI, P)Long-term mortality0.6 (0.4-0.9; P = .011)1-year stroke-free survival1.1 (0.3-3.9; P = .878)1-year reintervention-free survival5.0 (0.8-33.0; P = .091)HR, Hazard ratio; OR, odds ratio. Open table in a new tab

(434) Value of Office Pre-Operative Cystoscopy Prior to Penile Prosthesis Surgery

Abstract Introduction Discovery of obstructive urethral pathology, such as urethral stricture, benign prostatic hyperplasia (BPH), or bladder neck contracture (BNC), during inflatable penile prosthesis (IPP) placement may result in aborted prosthetic implantation. Routine pre-operative office cystoscopy to evaluate for obstructive urethral pathology would likely prevent aborted implant cases. However, routine cystoscopy would also represent a substantial cost to the patient and healthcare system, especially since urethral pathology resulting in aborted cases is anecdotally rare. Objective Our objective was to evaluate the incidence of unexpected obstructive urethral pathology resulting in aborted IPP cases and then compare the cost of aborted cases to the cost of routine pre-operative office cystoscopy for all planned implants. Methods We retrospectively evaluated completed and aborted IPP placements by a high-volume surgeon from 1/1/2014 through 5/23/2022 for both virgin (CPT 54405) and revision (54410) IPPs, with further selected assessment of cases with concomitant cystoscopy (52000), urethral dilation (52281), and direct vision internal urethrotomy (55276). Selected cases were reviewed for additional patient information including prior urologic surgery, pelvic radiation, and clinical information regarding intra-operative cystoscopy. Cost analysis was conducted for office cystoscopy and operative costs associated with IPP cases based on institutional cost data. Outcomes evaluated included incidence of unexpected obstructive urethral pathology requiring aborted IPP placement, break-even points for office cystoscopy compared to cost of aborted IPP cases, and ‘number needed to scope’ to avoid an aborted implant. Results From a total of 822 IPP cases performed, 17 (2.1%) had concomitant cystoscopy, of which 11 (1.3%) were unplanned. Nine cystoscopies (1.1%) resulted from inability to place a urethral catheter secondary to urethral stricture (n=5), BNC (n=2), BPH (n=1), and no identifiable pathology (n=1). Three IPPs (0.4%) were aborted due to dense urethral stricture at a total cost of $42,982, with ‘number need to scope’ of 274 to avoid an aborted implant. With total calculated cost for office cystoscopy for all planned IPPs of $164,498 ($200.12 per patient), the rate of aborted IPP due to urethral pathology would need to exceed 1.4% to make routine office cystoscopy cost saving (Figure 1). Alternatively, at the observed incidence of aborted IPP (0.4%), routine office cystoscopy would need to cost $50.50 to break-even with the cost of aborted IPPs. Conclusions Unexpected obstructive urethral pathology resulting in aborted IPP is rare. As a result, routine pre-operative office cystoscopy for asymptomatic men prior to IPP does not provide cost savings at our institution. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Dr. Aaron Lentz is a speaker, preceptor, and consultant for Boston Scientific and Coloplast. Dr. Faysal Yafi is a speaker, advisor and consultant for Coloplast, Antares Pharma, Clarus Therapeutics, Promescent, Acerus, Sprout and Cynosure.

(242) Antimicrobial Prophylaxis for Inflatable Penile Prosthesis Surgery: Trends after Publication of the AUA Best Practice Statement

Abstract Introduction In April 2008, the American Urological Association (AUA) released a Best Practice Statement on antimicrobial use in urologic surgery, in which the combination of an aminoglycoside with either vancomycin or a 1st/2nd generation cephalosporin was recommended as the preferred antimicrobial regimen for inflatable penile prosthesis (IPP) implantation. This recommendation has come under scrutiny due to weak evidence supporting these combinations. Objective To assess changes in antibiotic prophylaxis for IPP surgery following publication of the AUA Best Practice Statement in April 2008. Methods The Premier Healthcare Database, an all-payer dataset that captures approximately 20% of hospital discharges in the United States, was queried for IPP surgeries from January 2000 to March 2020. The primary outcome was administration of an AUA-adherent antimicrobial regimen and secondary outcome was 90-day explant. Piecewise linear regression was used to compare antimicrobial trends before vs. after guideline publication. Multivariable logistic regression models were constructed for primary and secondary outcomes. Results A total of 26,574 patients who underwent IPP surgery were identified, of whom 17,754 (67%) received AUA-adherent antibiotics. After guideline publication, there was a 42% relative increase in AUA-adherent regimen usage, with an increase in the usage trend on piecewise linear regression (from 0.1% to 0.8% of encounters per quarter, R2=0.75, p&amp;lt;0.001). Increased usage trends were also observed for gentamicin (from 0.0% to 1.0% of encounters per quarter, R2=0.84, p&amp;lt;0.001) and vancomycin (0.1% to 0.7%, R2=0.77, p&amp;lt;0.001). On multivariable regression, odds of AUA-adherence increased after guideline publication (OR: 1.67, 95% CI: 1.54 – 1.80, p&amp;lt;0.001) and with surgery by a high-volume surgeon (OR: 2.21, 95% CI: 2.07 – 2.35, p&amp;lt;0.01). The risk of 90-day IPP explant was not associated with adherence to an AUA-recommended regimen (OR: 0.94, 95% CI: 0.75 – 1.18, p=0.6). Conclusions Publication of the AUA Best Practice Statement on Antimicrobial Prophylaxis was associated with a subsequent increase in the usage of AUA-recommended antibiotic regimens, with gentamicin and vancomycin being the most frequently used combination. No association was observed between AUA-adherent regimens and risk of 90-day explant. These findings suggest that the AUA Best Practice Statement, among other relevant communications on antimicrobial use at the time, led to significant changes in prophylactic antibiotic choice in IPP surgery, despite the absence of level-1 evidence regarding a superior choice. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Roman Health.

(471) The Transfacial Fixation of an Ectopic Low Submuscular Reservoir: A Novel Approach to Inflatable Penile Prosthesis Reservoir Placement

Abstract Introduction Ectopic reservoir placement has become a more routine practice among high-volume penile prosthesis implanters. In particular, the low submuscular approach has gained considerable popularity given its safe location away from structures of concern such as the iliac vein or bowel, which can frequently be in the proximity of reservoirs placed in the traditional Space of Retzius position in patients with prior pelvic procedures such as a radical prostatectomy. However, the low submuscular approach is not without its own risks, most notably, herniation of the reservoir to an unintended location. In order to maximize the benefits of submuscular reservoir placement and minimize risk for herniation, we describe a novel approach to low submuscular reservoir placement. Objective The objective of this study is to present outcomes data on inflatable penile prosthesis patients who underwent low submuscular (LSM) reservoir placement with transfascial fixation (TFF). Methods A retrospective review was conducted on patients who underwent an IPP placement using the LSM with TFF technique between June 2019 and March 2022 by a single, high-volume surgeon at a tertiary medical center. Preoperative patient characteristics were collected, and patients then conducted a telephone interview with a modified questionnaire to assess satisfaction with the IPP and reservoir concealment. Results A total of 34 patients underwent IPP surgery with low submuscular reservoir placement with TFF of which 29 completed the questionnaire (85.2%). The average age of patients was 68.3 years, and 61.5% of patients had undergone a radical prostatectomy. Overall satisfaction with the penile implant was 4.1 (out of 5). Eight patients (26%) were able to palpate the reservoir, and four patients (15.4%) were able to visualize the reservoir impression below the abdominal skin. However, overall satisfaction with reservoir concealment was 4.6 (out of 5) (Table 1). No surgical revisions were required and there were no surgical complications such as bowel obstruction, herniations, bladder erosion, or vascular injuries. Conclusions Low submuscular IPP reservoir placement with TFF is an alternative approach for reservoir placement with a high degree of patient satisfaction, decreased risk for reservoir herniation, and significant ease of placement compared to alternative methods in the literature. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific

(438) An Inflatable Penile Prosthesis Manufacturer Recall: What do the Real Numbers Show from a Single High-volume Center?

Abstract Introduction The inflatable penile prosthesis (IPP) is considered the gold standard in the treatment of erectile dysfunction. As such, there have been a multitude of mechanical improvements over the recent decades. Despite these advances, there have been device recalls in the past. Some required revision surgery. A large retrospective study in 1995 from Drs. Wilson and Delk illustrated that revision surgery has an increased risk of infection of approximately 10%. However, this is most likely higher in lower volume institutions. In May of 2020, a major IPP device company released a letter issuing an urgent Class 2 medical device recall for their AMS 700 Momentary Squeeze Pumps (Boston Scientific, Marlborough, MA, USA) due to an increasing number of complaints due to failure of pump activation over a several year period. After investigation, a defective pump mold was found to be the etiology. There were only 2 pump molds; yet it is estimated that only up to 2% of devices would be affected. Objective We aim to investigate the actual device defect rate in clinical practice and to bring to light the cost of revision IPP surgery to our health system and patients. Methods We retrospectively reviewed charts from a single high-volume IPP surgeon from January 2018-December 2020 for virgin and replacement IPP patients. Those having Coloplast devices or malleable implants were excluded. Costs of revision surgery were also researched at the senior author’s facility. Results A total of 154 patients were identified. 42/154 (27%) patients were identified as removal and replacements and 112/154 (73%) were virgin cases. Of the 154 patients, 13/154 (8.4%) patients had pump failure. 5/112 (4.5%) were virgin cases and 8/42 (19%) patients were removal and replacements. These numbers do not include patients that have fickle pumps that were conservatively managed or implants that were identified as defective intraoperatively, which would greatly inflate these numbers. Cost analysis at our institution revealed direct costs that far exceed the price of the replacement device (list price $15,100; average is ~$14,000). However, these direct costs do not include the costs of convalescence, loss of work, or if any complications arise from the revision surgery. Conclusions We found that the stated rate of affected AMS 700 MS pumps to be approximately 4 times greater than previously stated at a rate of 8.4%. Including fickle pumps or grossly defective devices during the index surgery in this analysis would undoubtedly increase these numbers significantly. The company’s recall policy is also limited as it only considers malfunctions brought to its attention within 2 months of surgery. The cost to the patient and/or the hospital system far exceeds the cost of the replacement device itself. Further analysis should be performed. A more expeditious process for evaluating device complaints and more transparency from manufacturers should be implemented to improve patient satisfaction and outcomes. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast, Irrimax, MicrogenDx, Signati Medical, Endo, Pfizer, Procept Robotics

(516) Maximizing Penile Prosthesis Length: Our Technique and Outcomes

Abstract Introduction The most common cause of patient regret after penile prosthesis surgery is penile shortening, which has been reported in up to 70% of patients postoperatively. Objective We sought to query a national database on average prosthesis length and describe our techniques to maximize cylinder sizes. Methods We performed a retrospective review of the Coloplast database of 3-piece penile prosthesis cases performed over the span of 1 year nationally and by a single high volume surgeon and compared average cylinder lengths. Results Between July 1, 2021 and June 27, 2022, 145 three piece penile prosthesis surgeries were performed at our institution. All were performed via a scrotal incision. Nationally, 32.8% were performed infrapubic while 58.1% were performed scrotal. The most prevalent cylinder length in our series was 22cm, compared to the most prevalent nationally of 20cm. (Table 1). Our technique to maximize cylinder length involves circumferential mobilization of the corporal bodies and corporal tissue sparing. After initial scrotal incision and dissection to the level of the penile compartment, circumferential mobilization of the corporal bodies is carried out. In addition, the ventral corporal dartos layer is meticulously peeled away. Corporal tissue sparing is carried out by employing 9” Metzenbaum scissors rather than sequential dilators for corporal tunneling. (Image 1). The benefit of this approach is the ability to create a dorsal compartment to the level of the triangular ligament of the glans, thereby extending the space to the level of the midglans. This maneuver minimizes placement of the prosthesis anteriorly at the level of the fossa navicularis and prevents floppy glans that would otherwise compromise maximum cylinder length. Conclusions Three piece penile prosthesis cylinder size can be maximized by circumferential mobilization of the corporal bodies, corporal sparing maneuvers, and the utilization of long Metzenbaum scissors for precise corporal tunneling, ensuring the distal cylinder tips are seated within the tip of the glans rather than at the coronal sulcus. This can help mitigate patient regret after prosthesis surgery. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

Improving outcomes of surgery for acute type A aortic dissection

Background. It remains equivocal if acute type A aortic dissection (ATAAD) surgical outcomes are improving. We analyzed current outcome trends to evaluate improvements and to identify predicting variables. Methods. From 2015 to 2020, 204 patients underwent surgery for ATAAD and were divided into recent (n = 102) and earlier (n = 102) groups. Uni- and multivariable statistical analysis was performed to identify predictors of 30-day mortality. Results. Thirty-day mortality decreased significantly in the recent group (3.9% vs 14.6%, p = .014). Prevalence of neurological insult also decreased significantly (13% vs 25%, p = .028). Other major complications remained unchanged. There was no statistically significant difference in overall 30-day mortality between low-volume vs high-volume surgeons (12.3% vs 7.3%, p = .21). The number of surgeons performing ATAAD procedures decreased from nine in 2015 to five in 2020. Preoperative lactate (OR 1.24, 95%CI 1.03–1.51), dissection of any arch vessel (OR 14.2, 95%CI 1.79–113), non-normal left ventricular ejection fraction (OR 12.5, 95%CI 2.54–61.6), biological composite graft (OR 19.1, 95%CI 2.75–133), concomitant coronary artery bypass grafting (OR 38.8, 95%CI 2.91–517) and intraoperative adverse event (OR 9.5, 95%CI 2.22–40.9) were statistically significant independent predictors of mortality. Conclusions. Early outcomes after ATAAD improved in the most recent experience. Part of the explanation may be fewer surgeons performing more procedures annually, a relatively conservative approach to the extent of aortic resection and ensuring adequate cerebral protection. Major complications remain prevalent and require attention to be further reduced.

A-247 IMPACT OF ADRENAL SURGEON VOLUME ON OUTCOME: ANALYSIS OF THE UNITED KINGDOM REGISTRY OF ENDOCRINE AND THYROID SURGERY (UKRETS)

Abstract Background Although there is surgeon volume-outcome effect in adrenal surgery the threshold for ‘high volume’ surgeon remains controversial. This retrospective cohort study of the UKRETS database explores this issue further. Methods Adrenal data on adults aged 18–90 years from 2004 to 2021 was analysed. Outcomes included postoperative complications, post-operative, length of stay (LOS) and mortality. Factors included in multivariable analysis were patient age, gender, diagnosis, surgical approach, anatomy, and surgeon volume. Cases with missing data on any variable and LOS &amp;gt; 60 days were excluded. Results Of 6174 operations, 4464 (72.3%) cases were analysed. Postoperative complications occurred in 418/4064 (9.4%) and mortality in 14/4064 (0.3%). Median LOS was 3 (IQR 2-5) days. Co-variables significantly (p&amp;lt;0.05) associated with adverse outcomes were: postoperative complications - age [OR 1.02 (95% CI 1.01-1.03)], adrenal cancer [OR 1.64 (95% CI 1.14-2.36)], bilateral surgery [OR 1.66 (95% CI 1.03-2.69)] and surgeon volume [OR 0.98 (95% CI 0.96-0.99)]; mortality - age [OR 1.08 (95% CI 1.03-1.13)], laparoscopic approach [OR 0.08 (95% CI 0.02-0.27)] and bilateral surgery [OR 6.93 (95% CI 1.40-34.34)] and LOS (standardised beta co-efficient) - male sex (-0.03), age (0.09), phaeochromocytoma (0.07), adrenal cancer (0.08), bilateral surgery (0.11), laparoscopic approach (-0.40) and surgeon volume (-0.06). Conclusion Surgery for adrenal cancer and bilateral tumours could be restricted to high volume surgeons, but the threshold still needs to be defined.

Pelvic Floor Muscle Function and Its Relationship with Post-Prostatectomy Incontinence

ObjectivesPost-prostatectomy incontinence (PPI) is a common condition, but the underlying mechanisms are not completely understood. Transperineal ultrasound (TPUS) assessment of voluntary pelvic floor muscle (PFM) function may be associated with PPI. This study investigates the relationship between PPI and pre- and postoperative displacement of anatomical landmarks related to PFM function.MethodsThis was a prospective longitudinal cohort study of 40 patients undergoing robotic-assisted radical prostatectomy (RARP) by a high-volume single surgeon. All patients underwent PFM training pre- and postoperatively. TPUS was used to obtain sagittal images of pelvic structures during maximal voluntary PFM contractions: (1) preoperatively, (2) 3 weeks postoperatively, and (3) 6 weeks postoperatively. TPUS images were analyzed to calculate displacement of anatomical landmarks associated with activation of striated urethral sphincter (SUS), bulbocavernosus muscle (BC), and puborectalis muscle (PR). Continence was assessed at 3 and 6 weeks postoperatively, defined as use of ≤ 1 pad/day. The relationship of continence to the displacement of SUS, BC, and PR was analyzed.ResultsSUS, BC, and PR displacement decreased significantly 3 weeks postoperatively (P = 0.042, P = 0.002, P &lt; 0.001, respectively). Continent men exhibited significantly greater SUS displacement (median, 5.13 mm) than incontinent men (median, 3.90 mm) 3 weeks postoperatively (P = 0.029). Between 3 and 6 weeks following RARP, there was significant increase in SUS, BC, and PR displacement (P = 0.003, P = 0.030, P &lt; 0.001, respectively).ConclusionsA significant decrease in PFM function occurs following RARP, with a subsequent recovery of postoperative PFM function between 3 and 6 weeks post-procedure in men who undergo PFM training. SUS activation was significantly greater in continent patients compared to incontinent patients at 3 weeks following RARP.

Low-volume surgeons can have better outcomes at certain hospital settings for open abdominal aortic repairs

ObjectiveThe volume-outcomes relationship is cross-cutting among open abdominal aortic operations, where higher-volume surgeons have better perioperative outcomes. However, there has been minimal focus on low-volume surgeons and how to improve their outcomes. This study sought to identify if there are any differences in outcomes among low-volume surgeons for open abdominal aortic surgeries by different hospital settings. MethodsWe used the 2012-2019 Vascular Quality Initiative registry to identify all patients who underwent open abdominal aortic surgery for aneurysmal or aorto-iliac occlusive disease by a low-volume surgeon (<7 operations annually). We categorized high-volume hospitals using three distinct definitions: those that performed ≥10 operations annually, those with at least one high-volume surgeon, and by the number of surgeons (1-2 surgeons, 3-4 surgeons, 5-7 surgeons, and 8+ surgeons). Outcomes included 30-day perioperative mortality, overall complications, and failure-to-rescue. We compared outcomes among low-volume surgeons using univariable and multivariable logistic regressions across each of these three hospital categorizations. ResultsAmong 14,110 patients who underwent open abdominal aortic surgery, 10,252 (7 3%) were performed by 1155 low-volume surgeons. Two-thirds of these patients (66%) underwent their surgery at a high-volume hospital, fewer than one-third (30%) at a hospital that had at least one high-volume surgeon, and one-half (49%) at hospitals with at least five surgeons. Among all patients operated on by low-volume surgeons, rates of 30-day mortality were 3.8%, perioperative complications were 35.3%, and failure-to-rescue were 9.9%. Low-volume surgeons operating at high-volume hospitals for aneurysmal disease had lower rates of perioperative death (adjusted odds ratio [aOR], 0.66; 95% confidence interval [CI], 0.48-0.90) and failure-to-rescue (aOR, 0.70; 95% CI, 0.50-0.98), but similar rates of complications (aOR, 1.06; 95% CI, 0.89-1.27). Similarly, patients undergoing their operation at hospitals that had at least one high-volume surgeon had lower rates of death (aOR, 0.71; 95% CI, 0.50-0.99) for aneurysmal disease. Patient outcomes among low-volume surgeons for aorto-iliac occlusive disease did not vary by hospital setting. ConclusionsThe majority of patients undergoing open abdominal aortic surgery have a low-volume surgeon, where outcomes are slightly better for those taking place at a high-volume hospital. Focused and incentivized interventions may be needed to improve outcomes among low-volume surgeons across all practice settings.

Trends in Utilization of Completion Imaging after Lower Extremity Bypass and Its Association with Major Adverse Limb Events and Loss of Primary Patency

Failure following lower extremity bypasses (LEBs) isoften secondary to technical defects. Despite traditional teachings, routine use of completion imaging (CI) in LEB has been debated. This study assesses national trends of CI following LEBs and the association of routine CI with 1-year major adverse limb events (MALE) and 1-year loss of primary patency (LPP). The Vascular Quality Initiative (VQI) LEB dataset from 2003-2020 was queried for patients who underwent elective bypass for occlusive disease. The cohort was divided based on surgeons' CI strategy at time of LEB, categorized as routine (≥80% of cases/year), selective (<80% of cases/year), or never. The cohort was further stratified by surgeon volume category [low (<25th percentile), medium (25th-75th percentile), or high (>75th percentile)]. The primary outcomes were 1-year MALE-free survival and 1-year loss of primary patency (LPP)-free survival. Our secondary outcomes were temporal trends in CI use and temporal trends in 1-year MALE rates. Standard statistical methods were utilized. We identified 37,919 LEBs; 7,143 in routine CI strategy cohort, 22,157 selective CI and 8,619 in never CI. Patients in the 3 cohorts had comparable baseline demographics and indications for bypass. There was a significant decrease in CI utilization from 77.2% in 2003 to 32.0% in 2020 (P<0.001). Similar trends in CI use were observed in patients who underwent bypass to tibial outflows (86.0% in 2003 vs. 36.9% in 2020; P<0.001). While the use of CI has decreased over time, 1-year MALE rates have increased from 44.4% in 2003 to 50.4% in 2020 (P<0.001). On multivariate COX regression, however, no significant associations between CI use or CI strategy and risk of 1-year MALE or LPP was found. Procedures performed by high-volume surgeons carried a lower risk of 1-year MALE (HR: 0.84; 95% CI [0.75-0.95]; P=0.006) and LPP (HR:0.83; 95% CI [0.71-0.97]; P<0.001) compared to low-volume surgeons. Repeat adjusted analyses showed no association between CI (use or strategy) and our primary outcomes when the subgroups with tibial outflows were analyzed. Similarly, no associations were found between CI (use or strategy) and our primary outcomes when the subgroups based on surgeons' CI volume were evaluated. The use of CI, for both proximal and distal target bypasses, has decreased over time while 1-year MALE rates have increased. Adjusted analyses indicate no association between CI use and improved MALE or LPP survival at 1year and all CI strategies were found to have equivalent outcomes.

Mesh-based inguinal hernia repairs in an integrated healthcare system and surgeon and hospital volume: a cohort study of 110,808 patients from over a decade.

The aim of this study was to describe a cohort of patients who underwent inguinal hernia repair within a United States-based integrated healthcare system (IHS) and evaluate the risk for postoperative events by surgeon and hospital volume within each surgical approach, open, laparoscopic, and robotic. Patients aged ≥ 18years who underwent their first inguinal hernia repair were identified for a cohort study (2010-2020). Average annual surgeon and hospital volume were broken into quartiles with the lowest volume quartile as the reference group. Multiple Cox regression evaluated risk for ipsilateral reoperation following repair by volume. All analyses werestratified by surgical approach (open, laparoscopic, and robotic). 110,808 patients underwent 131,629 inguinal hernia repairs during the study years; procedures were performed by 897 surgeons at 36 hospitals. Most repairs were open (65.4%), followed by laparoscopic (33.5%) and robotic (1.1%). Reoperation rates at 5 and 10years of follow-up were 2.4% and 3.4%, respectively; rates were similar across surgical groups. In adjusted analysis, surgeons with higher laparoscopic volumes had a lower reoperation risk (27-46average annual repairs: hazard ratio [HR] = 0.63, 95% confidence interval [CI] 0.53-0.74; ≥ 47 repairs: HR 0.53, 95% CI 0.44-0.64) compared to those in the lowest volume quartile (< 14 averageannualrepairs). No differences in reoperation rates were observed in reference to surgeon or hospital volume following open or robotic inguinal hernia repair. High-volume surgeons may reduce reoperation risk following laparoscopic inguinal hernia repair. We hope to better identify additional risk factors for inguinal hernia repair complications and improve patient outcomes with future studies.

Redo thyroidectomy: A modified technique to eliminate complications

Introduction: Reoperation is the most challenging task in thyroid surgery because of the high risk of complications. This study aims to demonstrate the efficacy of a modified thyroidectomy technique in decreasing associated complications to almost zero in recurrent thyroidectomy. Methods: This single-group cohort study enrolled consecutive patients who had a recurrent thyroidectomy. The patients were examined for vocal cord motility preoperatively. The procedures were done by high-volume surgeons using a modified thyroidectomy technique, which included the following steps:1) Finding and preserving parathyroid glands before searching for the recurrent laryngeal nerve; 2) Expecting the recurrent laryngeal nerve in any area of the neck until it is found; 3) Starting the dissection in the suprasternal notch to find the recurrent laryngeal nerve in the tracheoesophageal groove; 4) If the nerve was not found in the suprasternal notch, the search would continue at the nerve's expected entrance to the cricoid cartilage. Results: In total, 195 cases with redo thyroidectomy were enrolled in this study. Female patients (173, 88.7%) were predominant compared to males (22, 11.3%). The most common ultrasonographic finding was multinodular goiter in 138 cases (70.7%). Most of the cases underwent total thyroidectomy (160, 82%), and thyroid lobectomy was performed in 35 cases (18%). In all the cases that underwent total thyroidectomy, both recurrent laryngeal nerves were explored, and the concerned lateral recurrent laryngeal nerve was seen during the thyroid lobectomies. There was no injury to recurrent laryngeal nerves, and only 15% of the cases suffered from temporary hypocalcemia. Conclusion: Recurrent thyroidectomy without significant complications is possible when conducted by high-volume surgeons, and a modified technique is used.

Does Obesity Impact Outcomes of Total Knee Arthroplasty When Treated by High-Volume Surgeons? A Propensity-Matched Analysis From a High-Volume Urban Center

BackgroundThe impact of morbid obesity (MO) on outcomes following total knee arthroplasty (TKA) when performed by high-volume (HV) surgeons has not been investigated. This study aimed to assess complication rates and implant survivorship in MO patients operated on by HV surgeons. MethodsPatients undergoing primary, elective TKA between June 2011 and May 2022 with a HV surgeon (top 25% surgeons by the number of primary TKAs per year) were retrospectively reviewed. Patients were stratified by body mass index (BMI) into 3 groups: BMI ≥40 (MO), 30≤ BMI <40 (non-morbidly obese), and BMI <30 (nonobese) and 1:1:1 propensity matched based on baseline characteristics. Of the 12,132 patients evaluated, 1,158 were included in final matched analyses (386 per group). The HV surgeons performed a median of 104 TKAs annually (range, 90-173). ResultsThe MO patients had significantly longer surgery duration (P = .006) and hospital lengths of stay (P < .001). The 90-day postoperative complications (P = .38) and readmission rates (P = .39) were comparable between groups. Rates of all-cause, septic and aseptic revision were similar between groups at two-year (P = .30, P = .15, and P = .26, respectively) and the latest follow-up (P = .36, P = .52, and P = .38, respectively). Improvement in Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) scores at 6 months (P = .049) and one year (P = .015) was significantly higher in MO patients. ConclusionClinical outcomes and complication rates following TKA by HV surgeons are comparable regardless of obesity status. The MO patients may benefit from referral to experienced surgeons to minimize procedural risks and improve outcomes. Level of EvidenceIII.

Integrating a tumour appropriate transanal or robotic assisted approach to total mesorectal excision in high-volume rectal cancer practice is safe and cost-effective.

Total mesorectal excision (TME) is accepted as the gold standard for oncological resection in rectal cancer. The best approach to TME is debated and often surgeons will select a preferred approach. In this study, we aimed to describe how both robotic (R-TME) and transanal (TaTME) TME can be integrated into high-volume rectal cancer surgeon practice with a comparison of clinical and oncological outcomes and cost analysis. A prospective comparative cohort study was performed in a high-volume rectal cancer centre comparing the previous 50 R-TME and 50 TaTME performed by the same surgeon. A comparison of tumour characteristics was performed to highlight a specific role for each technique. Clinical outcomes (operative duration, length of stay (LOS) and perioperative morbidity), cancer quality indicators (resection margin and completeness of TME) and cost analysis were compared. Statistical analysis was performed using IBM SPSS, version 20. R-TME was preferred in mid-rectal cancer, compared to TaTME preferred in low rectal cancer (9cm vs. 5cm, p < 0.001). Operative duration was longer in R-TME compared to TaTME (265 vs. 179min, p < 0.001). Major complications (CD III-IV complications) were experienced in 10% of R-TME and 14% of TaTME (p = 0.476). A 98% (n = 49) clear R0 resection margin was achieved with both R-TME and TaTME and mesorectum quality defined as 'complete' in 86% (n = 43) in R-TME and 82% (n = 41) in TaTME. Length of hospital stay was shorter in R-TME (5 vs. 7days, p = 0.624). An overall difference of €131 was observed favouring TaTME. In high-volume rectal cancer surgery practice, both R-TME and TaTME can be practised and tailored according to patients and tumour characteristics, with comparable clinical and cancer outcomes and is cost-effective.

Vesicoprostatic muscle reconstruction: a step further for immediate and early urinary continence

The vesicoprostatic muscle (VPM) is a longitudinal smooth muscle that originates from the trigone of the bladder or the opening of the ureter and is involved in urination as part of the detrusor apron. We explored the effect of VPM reconstruction on immediate and early recovery of urinary continence in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP). A total of 523 patients with localized prostate cancer were enrolled from June 2018 to June 2020. All patients were diagnosed in our department based on magnetic resonance imaging and pathological findings on prostate biopsy. After 1:1 propensity score matching, 105 patient pairs were matched. The study was approved by our institutional review board and all surgeries were performed by three experienced high-volume surgeons. Demographic data, total operation time, pathological outcomes, the urinary continence rates of the two groups at different times after RALP, and factors influencing postoperative urinary continence after RALP were recorded. Student's t test was used to compare continuous variables and the Pearson χ2 test to compare categorical variables. Logistic regression analysis was used to identify factors affecting immediate and early postoperative urinary control. VPM reconstruction promoted immediate and early recovery of urinary continence (immediate continence, 66.67 vs. 40.00%, P = 0.000; 3-month continence, 80.95 vs. 64.76%, P = 0.008). VPM reconstruction improved immediate and early urinary continence in patients who underwent RALP.

Outcomes of Complex Endovascular Treatment of Post-Dissection Aneurysms

Reports of endovascular treatment of chronic post-dissection aneurysms are limited to high volumes centres, posing questions about generalisability. All endovascular repairs of intact pararenal and thoraco-abdominal aneurysms in the Vascular Quality Initiative from 2014 to 2021 were studied, and peri-operative and long term outcomes were compared between repairs of degenerative and post-dissection aneurysms. Peri-operative outcomes were compared using mixed effects logistic regression, and long term outcomes using Medicare linkage. There were 123 patients who completed treatment for post-dissection aneurysms and 3 635 for degenerative aneurysms, with 36% of post-dissection repairs and 6.7% of degenerative repairs performed in a staged fashion (p < .001). The majority (84%) of post-dissection aneurysms were extensive thoraco-abdominal aneurysms (TAAAs: Crawford Type 1, 2, 3, 5), compared with 22% of degenerative aneurysms (p < .001). Physician modified endografts were the primary repair type for post-dissection (73%), while commercially available fenestrated grafts were the dominant repair for degenerative (48%). The first stage of staged procedures was associated with a 2.8% peri-operative mortality rate, 5.1% spinal cord ischaemia, and 8.9% thoraco-abdominal life altering events (the composite of peri-operative death, stroke, permanent spinal cord ischaemia, and dialysis). Th final stage procedure and fluoroscopy times were similar, but technical success was lower in post-dissection repairs (75% vs. 83%, p= .018), both due to issues with the main endograft or bridging vessels (11% vs. 6.6%, p= .055), and types 1and 3 endoleak at completion (17% vs. 10%, p= .035). In addition, high volume surgeons had two fold higher odds of technical success than their low volume counterparts. Adjusted peri-operative outcomes were similar between pathology types, including when comparisons were restricted to extensive TAAAs. Crude and adjusted three year survival were similar, but three year re-interventions were significantly higher following post-dissection repairs (p < .001). Complex endovascular repair of chronic post-dissection aneurysms is feasible but is associated with high rates of re-interventions and non-trivial rates of lack of technical success. More data are needed to evaluate the long term durability of these procedures, and the utility of centralising these complex procedures.

Do ‘Surgeon Champions’ and High-Volume Surgeons Have Lower Rates of Periprosthetic Femur Fracture? Perspective From a State-Wide Quality Improvement Registry

BackgroundRecently, a state-wide registry identified fracture as a major cause of total hip arthroplasty revision. There were 52.8% of revisions occurring within 6 months (fracture leading cause). Registry sites have a ‘surgeon champion’ who acts as liaison and advocate. This study evaluated the effect of surgeon volume and role of ‘surgeon champion’ on fracture rates. MethodsThere were 95,948 cases from 2012 to 2019 queried with peri-implant femoral fractures identified (within 6 months). Funnel plots were generated to compare individual surgeon-specific fracture rates. Surgeons who had a fracture rate below the confidence interval were labeled ‘green’ (lower than mean), within were ‘yellow’ (no difference), and above were ‘red’ (significantly higher). ResultsFor all surgeons, 19.6% were red, 72.1% yellow, and 8.3% green. There were 17.2% ‘surgeon champions’ and 6.2% ‘nonchampions’ that were green (P = .01), while 20.7 and 19.3% were red (P = .82). There was a significant association between volume and performance (P < .01). No surgeons in the lower two quartiles (<84; 84 to 180 cases), while 4 and 29% of higher-volume surgeons (181 to 404; >404 cases) were green. There was no statistical difference in red status by volume (P = .53). Conclusion‘Surgeon champions’ and high-volume surgeons were more likely to be high performers but not less likely to be low performers. Active involvement in quality improvement and/or high volume was associated with better outcomes but did not impart complication immunity. ‘Green’ surgeons should mentor colleagues to help reduce fractures by re-evaluating modifiable factors. Analyzing outcomes to promote quality and decrease complications is paramount.