Incidence Of Major Postoperative Complications Research Articles

Combining systemic inflammatory response index and albumin fibrinogen ratio to predict early serious complications and prognosis after resectable gastric cancer.

Gastric cancer has a high incidence and fatality rate, and surgery is the preferred course of treatment. Nonetheless, patient survival rates are still low, and the incidence of major postoperative complications cannot be disregarded. The systemic inflammatory response, nutritional level, and coagulation status are key factors affecting the postoperative recovery and prognosis of gastric cancer patients. The systemic inflammatory response index (SIRI) and the albumin fibrinogen ratio (AFR) are two valuable comprehensive indicators of the severity and prognosis of systemic inflammation in various medical conditions. To assess the clinical importance and prognostic significance of the SIRI scores and the AFR on early postoperative outcomes in patients undergoing radical gastric cancer surgery. We conducted a retrospective analysis of the clinicopathological characteristics and relevant laboratory indices of 568 gastric cancer patients from January 2018 to December 2019. We calculated and compared two indicators of inflammation and then examined the diagnostic ability of combined SIRI and AFR values for serious early postoperative complications. We scored the patients and categorized them into three groups based on their SIRI and AFR levels. COX analysis was used to compare the three groups of patients the prognostic value of various preoperative SIRI-AFR scores for 5-year overall survival (OS) and disease-free survival (DFS). SIRI-AFR scores were an independent risk factor for prognosis [OS: P = 0.004; hazards ratio (HR) = 3.134; DFS: P < 0.001; HR = 3.543] and had the highest diagnostic power (area under the curve: 0.779; 95% confidence interval: 0.737-0.820) for early serious complications in patients with gastric cancer. The tumor-node-metastasis stage (P = 0.001), perioperative transfusion (P = 0.044), positive carcinoembryonic antigen (P = 0.014) findings, and major postoperative complications (P = 0.011) were factors associated with prognosis. Preoperative SIRI and AFR values were significantly associated with early postoperative survival and the occurrence of severe complications in gastric cancer patients.

Origin and Clinical Impact of Early Multidrug-Resistant (MDR) Contamination in Patients Undergoing Pancreaticoduodenectomy

Introduction: Infections caused by multidrug-resistant bacteria (MDR) occur more frequently after pancreaticoduodenectomy (PD) compared to other abdominal surgeries, and infective complications represent a major determinant of postoperative morbidity following PD. Preoperative biliary stent (PBS) placement often leads to biliary contamination, which plays a significant role in postoperative infections. The aim of this study is to evaluate the impact of MDR contamination on short-term postoperative outcomes in patients undergoing PD and to evaluate the relationship between MDR bacteria, PBS, and bile contamination. Methods: This is a retrospective study based on a prospectively maintained database including 825 consecutive patients who underwent pancreaticoduodenectomies (PDs). All procedures were performed by experienced pancreatic surgeons at a high-volume center and the patients were managed according to the same perioperative enhanced recovery protocol. Results: MDR bacteria were present in 17.5% of bile cultures, exclusively within the stented group. At the multivariate analysis, the development of major postoperative complications (MPC) was correlated with the presence of MDR bacteria in the bile (OR 1.66, 95% CI: 1.1–2.52; p = 0.02). MDR bacteria were detected early in the surgical drainage in 144 out of 825 patients (12.1%), with 72.2% having a previous biliary stent placement and 27.8% without stents (p &lt; 0.001). Moreover, the development of an MPC was associated with the presence of MDR bacteria in the drainage (OR = 1.81, 95% CI: 1.21–2.73, p = 0.0042). Conclusions: We demonstrated that MDR contamination worsens the short-term outcomes of patients undergoing PDs. Specifically, when MDR bacteria are present in both the bile and drainage, there is a statistically significant increase in the incidence of major postoperative complications (MPC). Our data suggest that the majority of MDR surgical site infections stem from biliary contamination resulting from the placement of a preoperative biliary stent (PBS).

Short-term outcomes of the TRIANGLE operation after neoadjuvant chemotherapy in locally advanced pancreatic cancer

Objective: To investigate the safety and efficacy of the TRIANGLE operation after neoadjuvant chemotherapy in locally advanced pancreatic cancer(LAPC). Methods: This study is a retrospective case series analysis. Between January 2020 and December 2022, a total of 103 patients were diagnosed as LAPC who underwent neoadjuvant chemotherapy at the Pancreas Center, the First Affiliated Hospital of Nanjing Medical University. Among them, 26 patients (25.2%) underwent the TRIANGLE operation. There were 15 males and 11 females,with a age of (59±7) years (range: 49 to 74 years). The pre-treatment serum CA19-9(M(IQR)) was 248.8(391.6)U/ml (range: 0 to 1 428 U/ml),and the serum carcinoembryonic antigen was 4.1(3.8)μg/L(range: 1.4 to 13.4 μg/L). The neoadjuvant chemotherapy regimens included: mFOLFIRINOX regimen in 6 cases(23.1%), GnP regimen in 14 cases(53.8%), and mFOLFIRINOX+GnP regimen in 6 cases(23.1%). The follow-up duration extended until June 2023 or until the occurrence of the patient's death or loss to follow-up. The Kaplan-Meier method was employed to estimate the 1-year and 3-year overall survival rates. Results: After neoadjuvant chemotherapy,CA19-9 levels decreased by 92.3(40.1)%(range:2.1% to 97.7%). Evaluation of the response to treatment revealed 13 cases(50.0%) of stable disease,11 cases(42.3%) of partial response,and 2 cases(7.7%) of complete response. The surgical operation consisted of 12 cases(46.2%) of pancreaticoduodenectomy,12 cases(46.2%) of distal pancreatectomy,and 2 cases(7.7%) of total pancreatectomy. Margin determination was based on the "standardised pathology protocol" and the "1 mm" principle. No R2 and R1(direct) resections were observed,while the R0 resection rate was 61.5%(16/26), and the R1(1 mm) resection rate was 38.5%(10/26).The R1(1 mm) resection rates for the anterior margin,posterior margin,transected margin,portal vein groove margin,and uncinate margin were 23.1%(6/26),19.2%(5/26),12.5%(3/24),2/14, and 1/12, respectively. The overall postoperative complication rate was 57.8%(15/26),with major complications including grade B/C pancreatic fistula 25.0%(6/24,excluding 2 cases of total pancreatectomy),delayed gastric emptying in 23.1%(6/26),wound complications 11.5%(3/26),postoperative hemorrhage 7.7%(2/26), chylous fistula 7.7%(2/26) and bile fistula 3.8%(1/26). No reoperation was performed during the perioperative period(<90 days). One patient died on the 32nd day postoperatively due to a ruptured pseudoaneurysm. A total of 25 patients were followed up,with a follow-up time of 21(24)months(range: 8 to 42 months). During the follow-up period,8 cases(32.0%) died due to tumor recurrence and metastasis,while 17 patients(68.0%) remained alive,including 11 cases of disease-free survival,5 cases of distant metastasis,and 1 case of local recurrence. The overall survival rates at 1- and 3-year after the initiation of neoadjuvant chemotherapy were 95.8% and 58.9%, respectively. The overall survival rates at 1- and 3-year after surgery were 77.7% and 57.8%, respectively. Conclusion: Performing pancreatoduodenectomy according to the Heidelberg triangle protocol in LAPC patients after neoadjuvant chemotherapy might increase the R0 resection rate without increasing perioperative mortality or the incidence of major postoperative complications.

Mortality and major postoperative complications within 1 year after vascular surgery: a prospective cohort study.

Patients undergoing vascular procedures are prone to developing postoperative complications affecting their short‑term mortality. Prospective reports describing the incidence of long‑term complications after vascular surgery are lacking. We aimed to describe the incidence of complications 1 year after vascular surgery and to evaluate an association between myocardial injury after noncardiac surgery (MINS) and 1‑year mortality. This is a substudy of a large prospective cohort study Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION). Recruitment took place in 28 centers across 14 countries from August 2007 to November 2013. We enrolled patients aged 45 years or older undergoing vascular surgery, receiving general or regional anesthesia, and hospitalized for at least 1 night postoperatively. Plasma cardiac troponin T concentration was measured before the surgery and on the first, second, and third postoperative day. The patients or their relatives were contacted 1 year after the procedure to assess the incidence of major postoperative complications. We enrolled 2641 patients who underwent vascular surgery, 2534 (95.9%) of whom completed 1‑year follow‑up. Their mean (SD) age was 68.2 (9.8) years, and the cohort was predominantly male (77.5%). The most frequent 1‑year complications were myocardial infarction (224/2534, 8.8%), amputation (187/2534, 7.4%), and congestive heart failure (67/2534, 2.6%). The 1‑year mortality rate was 8.8% (223/2534). MINS occurred in 633 patients (24%) and was associated with an increased 1‑year mortality (hazard ratio, 2.82; 95% CI, 2.14-3.72; P <0.001). The incidence of major postoperative complications after vascular surgery is high. The occurrence of MINS is associated with a nearly 3‑fold increase in 1‑year mortality.

Hypothermic oxygenated perfusion in liver transplantation: a meta-analysis of randomized controlled trials and matched studies.

Hypothermic oxygenated machine perfusion (HOPE) is a novel organ-preservation technology designed to optimize organ quality. However, the effects of HOPE on morbidity and mortality after liver transplantation remain unclear. This meta-analysis evaluated the potential benefits of HOPE in liver transplantation. The Embase, Web of Science, PubMed, Cochrane Library, and Scopus databases were searched for articles published up to 15 June 2023 (updated on 12 August 2023). Mean differences (MDs), risk ratios (RRs), and 95% confidence intervals were calculated. Eleven studies encompassing five randomized controlled trials and six matched studies were included, with a total of 1000 patients. HOPE did not reduce the incidence of major postoperative complications (RR 0.80), primary non-function (PNF) (RR 0.54), reperfusion syndrome (RR 0.92), hepatic artery thrombosis (RR 0.92), renal replacement therapy (RR 0.98), length of hospital stay (MD, -1.38 days), 1-year recipient death (RR 0.67), or intensive care unit stay (MD, 0.19 days) after liver transplantation. HOPE reduced the incidence of biliary complications (RR 0.74), non-anastomotic biliary strictures (NAS) (RR 0.34), early allograft dysfunction (EAD) (RR 0.54), and acute rejection (RR 0.54). In addition, HOPE improved the retransplantation (RR 0.42) and 1-year graft loss rates (RR 0.38). Compared with static cold storage (SCS), HOPE can reduce the incidence of biliary complications, NAS, EAD, and acute rejection and retransplantation rate after liver transplantation and improve the 1-year graft loss rate. These findings suggest that HOPE, when compared to SCS, can contribute to minimizing complications and enhancing graft survival in liver transplantation. Further research is needed to investigate long-term outcomes and confirm the promising advantages of HOPE in liver transplantation settings.

IBC-Oxford University2023_BJSOral_6Five years Follow up after Surgical Treatment of Type 2 Diabetes with Laparoscopic Sleeve Gastrectomy associated with a Duodenal Ileal Interposition

Abstract Introduction Type 2 diabetes mellitus (T2D) is a chronic disease, primarily caused by a combination of defective insulin secretion and the inability of insulin-sensitive tissues to respond to insulin. Laparoscopic sleeve gastrectomy associated with duodenal ileal interposition (SGDII) has been shown to be a feasible treatment option for patients with T2D, as it provides improvement and control of glycaemia, dyslipidaemia and arterial hypertension. The aim of this study was to evaluate the mid and long-term results of SGDII for the treatment of diabetic patients, considering diabetic remission, weight loss and postoperative complications. Materials and Methods Retrospective study with 96 patients with T2D submitted to SGDII, between 2010 and 2016. The glycated haemoglobin (HbA1c) value &amp;lt; 6.5%, without the use of hypoglycaemic agents, was considered as remission of T2D. Results The five years follow up demonstrated that 80% of patients had T2D remission at one year, 74.5% at three years and 61.8% at five years. The average duration of the disease was nine years and the mean glycated haemoglobin before surgery was 8.95%. Sixty-one patients (62.8%) were male, and 36 patients (37.2%) were female. The average age was 50.9 years. Median BMI was 33.43 kg/m2. The incidence of major postoperative complications in the first 30 days was 2.1%, with no mortality. Dyslipidaemia control was sustained, after five years, in 62% of the patients. Conclusion SGDII resulted in good glycaemic control at 5-years follow-up and represents a valid alternative for the treatment of T2D.

Preoperative nutritional support in patients undergoing pancreatic surgery affects PREPARE score accuracy.

This study aimed to validate the accuracy of the Preoperative Pancreatic Resection (PREPARE) risk score in pancreatic resection patients. This prospective study included 216 patients who underwent pancreatic resection between January 2015 and December 2018. All patients in our cohort with weight loss or lack of appetite received dietary advice and preoperative oral nutritional supplementation (600 kcal/day). Demographic, clinicopathological, operative, and postoperative data were collected prospectively. The PREPARE score and the predicted risk of major complications were computed for each patient. Differences in major postoperative complications were analyzed using a multivariate Cox proportional hazards regression model. The predicted and observed risks of major complications were tested using the C-statistic. The study included 216 patients [117 men (54.2%)] with a median age of 65.0 (30.0-83.0) years. The majority of patients were classified as American Society of Anesthesiologists (ASA)' Physical Status score II (N = 164/216; 75.9%) and as "low risk" PREPARE score (N = 185/216; 85.6%) before the surgery. Only 4 (1.9%) patients were malnourished, with albumin levels of less than 3.5 g/dl. The most common type of pancreatic resection was a pylorus-preserving pancreaticoduodenectomy (N = 122/216; 56.5%). Major morbidity and 30-day mortality rates were 11.1% and 1.9%, respectively. The type of surgical procedure (hazard ratio [HR]: 3.849; 95% confidence interval [CI]: 1.208-12.264) and ASA score (HR: 3.089; 95% CI: 1.067-8.947) were significantly associated with the incidence of major postoperative complications in multivariate analysis. The receiver operating characteristic curve was 0.657 for incremental values and 0.559 for risk categories, indicating a weak predictive model. The results of the present study suggest that the PREPARE risk score has low accuracy in predicting the risk of major complications in patients with consistent preoperative nutritional support. This limits the use of PREPARE risk score in future preoperative clinical routines.

Effectiveness of machine perfusion in liver transplantation: A meta-analysis of randomized controlled trials

BackgroundIn contemporary transplantation research, the utilization of machine perfusion to facilitate the perfusion, preservation, evaluation, and repair of donor livers has garnered considerable attention.In an effort to comprehensively assess the clinical outcomes of liver transplantation procedures incorporating machine perfusion, a meta-analysis of published randomized controlled trials (RCTs) was undertaken. MethodsThe relevant literature was obtained from PubMed, EMBASE, Web of Science, and other databases up until December 2022. Subsequently, the authors extracted the requisite data, conducted a meta-analysis, and arrived at a conclusion based on the findings derived from the analysis. ResultsA total of seven high-quality prospective RCTs, comprising 917 patients, were included in the analysis. Machine perfusion demonstrated significant superiority over cold storage in reducing the incidence of major postoperative complications (RR 0.55, 95% CI 0.42 to 0.73; p < 0.0001) and early allograft dysfunction (RR 0.52, 95% CI 0.41 to 0.67; p < 0.00001). Notably, postoperative aspartate aminotransferase peak, bilirubin levels, and post-reperfusion lactate were also found to decrease. However, no statistically significant differences were observed for other outcomes. Hypothermic oxygenation machine perfusion demonstrated a lower frequency of re-transplantation (RR 0.29, 95% CI 0.10 to 0.86; p = 0.03), rejection (RR 0.55, 95% CI 0.32 to 0.95; p = 0.03), and resulted in shorter hospital stays (Std, MD -0.30, 95% CI -0.52 to -0.07; p = 0.009). ConclusionsThe application of machine perfusion can yield significant improvements in the outcomes of liver transplantation.

Valve Sparing vs Composite Valve Graft Root Replacement: Propensity Score–Matched Analysis

BackgroundBoth valve-sparing root replacement and composite valve graft (CVG) are acceptable options in aortic root replacement. We compare outcomes of these 2 approaches and durability of the aortic valve. MethodsA consecutive 1635 patients without acute dissection underwent primary aortic root replacement from 1997 to 2022; 473 (29%) underwent valve-sparing root replacement, and 1162 (71%) received CVG. Propensity score matching was used to reduce baseline differences. ResultsThe CVG group was older (59 ± 14 years vs 49 ± 14 years; P < .001) with more comorbidities, such as hypertension (88.4% vs 66.4%; P < .001), diabetes (7% vs 1.7%; P < .001), ischemic heart disease (5.1% vs 1.3%; P = .001), pulmonary disease (6.6% vs 1.3%; P < .001), renal impairment (8.6% vs 1.3%; P < .001), class III-IV heart failure (35% vs 9.2%; P < .001), bicuspid aortic valves (44.8% vs 24.1%; P < .001), and severe aortic insufficiency (50.2% vs 13.2%; P < .001). Operative mortality was 0.4% (0% in valve sparing); incidence of major postoperative complications was 2.9% (3.6% vs 1.1%; P = .009). Ten-year survival was 93.1% (91.2% vs 97.7%; hazard ratio [HR], 1.7; 95% CI, 0.9-3.3; P = .120). Mean follow-up was 65 ± 60 months; aortic valve reoperations were similar (5.8% vs 5.7%; HR, 0.8; 95% CI, 0.4-1.4; P = .401). Recurrent moderate-severe aortic insufficiency was less prevalent in CVG (6.1% vs 11.1%; HR, 0.14; 95% CI, 0.07-0.27; P < .001). Propensity score matching identified 225 pairs. There was no difference in 10-year survival or reoperations. Recurrent moderate-severe aortic insufficiency was higher with valve sparing. ConclusionsBoth valve-sparing operations and CVG provide excellent early and late outcomes out to 10 years. Valve sparing is associated with a higher risk for development of aortic insufficiency but no difference in reoperations.

Short- and long-term results of total arch replacement: Comparison between island and debranching techniques.

The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching)or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta. The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models. The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P=.001), had undergone more previous cardiac operations (54.5% vs 27.4%, P<.001), and had more connective tissue disorder (20.3% vs 4.6%, P<.001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10minutes, P<.001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37minutes, P<.001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P=.018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P=.486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P=.897). Ten-year survival was 80% (78% vs 80.9%, log-rank P=.356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P=.495). Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.

Perioperative risk factors related to complications of lumbar spine fusion surgery in elderly patients

PurposeTo analyze the perioperative risk factors related to lumbar spine fusion surgery in elderly patients.Methods202 elderly patients (age range 77–92 years old) who have underwent lumbar spinal fusion surgeries between January 2019 and June 2021 were retrospectively investigated. Information of age, sex, comorbidity, fixation segments, operation time, surgical blood loss and perioperative complications during hospitalization were collected. Risk factors for complications were analyzed. Student’s t-test, chi-square test, Mann-Whitney U‑test and multivariate generalized linear models were used.ResultsIn this study, 31 patients presented complications (15.3%) in these elderly patients with an average age of 79.1 years, including 1 patient with intraoperative complication and 30 patients with postoperative complications; and 2 out of 31 patients (1%) died. The elderly patients were divided into group A (24 patients) with major postoperative complications and group B (178 patients) without major postoperative complications. Major postoperative complications were significantly associated with age (univariate analysis, t = 3.92, P < 0.001; multivariate analysis, OR = 1.323, 95%CI 1.126–1.554, P = 0.001), but not significantly associated with other factors tested (sex, comorbidity, fixation segments, operation time, surgical blood loss). Then 173 patients (range 77–81 years) were selected and the rate of major postoperative complications of each age from 78 to 81 years was compared with that of 77 years patients, respectively. We found that the ratios of complications at 80 years (OR = 10.000, P = 0.019) and 81 years (OR = 10.000, P = 0.009) were higher than the ratio at 77 years.ConclusionsAlthough with great progress of medical technology, increasing age was still the independent risk factor for major postoperative complications in elderly patients undergoing lumbar spinal fusion surgery. As for the incidence of major postoperative complications, 80 and 81 years old patients was 10 folds higher than that of 77 years old patients, reminding us to pay more attention to 80 years old and even older patients.

Changes in early postoperative outcomes and complications observed in a single center during the 2022 COVID-19 pandemic wave in China: A single-center ambispective cohort study.

Currently, the effect of the 2022 nationwide coronavirus disease 2019 (COVID-19) wave on the perioperative prognosis of surgical patients in China is unclear. Thus, we aimed to explore its influence on postoperative morbidity and mortality in surgical patients. An ambispective cohort study was conducted at Xijing Hospital, China. We collected 10-day time-series data from December 29 until January 7 for the 2018-2022 period. The primary outcome was major postoperative complications (Clavien-Dindo class III-V). The association between COVID-19 exposure and postoperative prognosis was explored by comparing consecutive 5-year data at the population level and by comparing patients with and without COVID-19 exposure at the patient level. The entire cohort consisted of 3350 patients (age: 48.5 ± 19.2 years), including 1759 females (52.5%). Overall, 961 (28.7%) underwent emergency surgery, and 553 (16.5%) had COVID-19 exposure (from the 2022 cohort). At the population level, major postoperative complications occurred in 5.9% (42/707), 5.7% (53/935), 5.1% (46/901), 9.4% (11/117), and 22.0% (152/690) patients in the 2018-2022 cohorts, respectively. After adjusting for potential confounding factors, the 2022 cohort (80% patients with COVID-19 history) had a significantly higher postoperative major complication risk than did the 2018 cohort (adjusted risk difference [aRD], 14.9% (95% confidence interval [CI], 11.5-18.4%); adjusted odds ratio [aOR], 8.19 (95% CI, 5.24-12.81)). At the patient level, the incidence of major postoperative complications was significantly greater in patients with (24.6%, 136/553) than that in patients without COVID-19 history (6.0% [168/2797]; aRD, 17.8% [95% CI, 13.6-22.1%]; aOR, 7.89 [95% CI, 5.76-10.83]). Secondary outcomes of postoperative pulmonary complications were consistent with primary findings. These findings were verified through sensitivity analyses using time-series data projections and propensity score matching. Based on a single-center observation, patients with recent COVID-19 exposure were likely to have a high incidence of major postoperative complications. NCT05677815 at https://clinicaltrials.gov/.

Long-term durability of valve-sparing root replacement in patients with and without connective tissue disease

ObjectiveThe goal of this study was to evaluate the long-term outcomes of valve-sparing root replacement in patients with connective tissue disease (CTD) and compare them with patients without CTD who underwent valve-sparing root replacement for root aneurysm. MethodsOf 487 patients, 380 (78%) did not have CTD and 107 (22%) had CTD; 97 (91%) with Marfan syndrome, 8 (7%) with Loeys-Dietz syndrome, and 2 (2%) with Vascular Ehlers-Danlos syndrome. Operative and long-term outcomes were compared. ResultsThe CTD group was younger (36 ± 14 years vs 53 ± 12 years; P < .001), had more women (41% vs 10%; P < .001) and had less hypertension (28% vs 78%; P < .001) and bicuspid aortic valve (8% vs 28%; P < .001). Other baseline characteristics did not differ between the groups. Overall operative mortality was nil (P = 1.000); the incidence of major postoperative complications was 1.2% (0.9% vs 1.3%; P = 1.000) and did not differ between groups. Residual mild aortic insufficiency (AI) was more frequent in the CTD group (9.3% vs 1.3%, P < .001) with no difference in moderate or greater AI. Ten-year survival was 97.3% (97.2% vs 97.4%; log-rank P = .801). Of the 15 patients with residual AI, 1 had none, 11 remained mild, 2 had moderate, and 1 had severe AI on follow-up. Ten-year freedom from moderate/severe AI was 89.6% (hazard ratio, 1.05; 95% CI, 0.8-1.37; P = .750) and 10-year freedom from valve reoperation was 94.9% (hazard ratio, 1.21; 95% CI, 0.43-3.39; P = .717). ConclusionsThe operative outcomes as well as long-term durability of valve-sparing root replacement is excellent in patients with or without CTD. Valve function and durability are not influenced by CTD.

Surgical Resection of Pulmonary Metastases from Melanoma in Oligometastatic Patients: Results from a Multicentric Study in the Era of Immunoncology and Targeted Therapy.

In the last decade, the emergence of effective systemic therapies (ESTs) in the form of both targeted and immuno-based therapies has revolutionized the treatment of patients with advanced stage III and stage IV melanoma. Even though lungs represent the most frequent site of melanoma metastases, only limited data are available on the role of surgery in isolated pulmonary metastases from malignant melanoma (PmMM) in the era of ESTs. The aim of this study is to describe the outcomes of patients who underwent metastasectomy of PmMM in the era of ESTs, in order to identify prognostic factors affecting survival and to provide a framework for more informed patient selection of treatmeant with lung surgery in the future. Clinical data of 183 patients who underwent metastasectomy of PmMM between June 2008 and June 2021 were collected among four Italian Thoracic Centers. The main clinical, surgical and oncological variables reviewed were: sex, comorbidities, previous oncological history, melanoma histotypes and primary site, date of primary cancer surgical treatment, melanoma growth phase, Breslow thickness, mutation pattern disease, stage at diagnosis, metastatic sites, DFI (Disease Free Interval), characteristics of lung metastases (number, side, dimension, type of resection), adjuvant therapy after lung metastasectomy, site of recurrence, disease-free survival (DFS) and cancer-specific survival (CSS; defined as the time interval between the first melanoma resection or lung metastasectomy and death from cancer). All patients underwent surgical resection of the primary melanoma before lung metastasectomy. Twenty-six (14.2%) patients already had a synchronous lung metastasis at the time of primary melanoma diagnosis. A wedge resection was performed in 95.6% of cases to radically remove the pulmonary localizations, while an anatomical resection was necessary in the remaining cases. The incidence of major post-operative complications was null, while only 21 patients (11.5%) developed minor complications (mainly air leakage followed by atrial fibrillation). The mean in-hospital stay was 4.46 ± 2.8 days. Thirty- and sixty-day mortality were null. After lung surgery, 89.6% of the population underwent adjuvant treatments (47.0% immunotherapy, 42.6% targeted therapy). During a mean FUP of 107.2 ± 82.3 months, 69 (37.7%) patients died from melanoma disease, 11 (6.0%) from other causes. Seventy-three patients (39.9%) developed a recurrence of disease. Twenty-four (13.1%) patients developed extrapulmonary metastases after pulmonary metastasectomy. The CSS from melanoma resection was: 85% at 5 years, 71% at 10 years, 54% at 15 years, 42% at 20 years and 2% at 25 years. The 5- and 10-year CSS from lung metastasectomy were 71% and 26%, respectively. Prognostic factors negatively affecting CSS from lung metastasectomy at multivariable analysis were: melanoma vertical growth (p = 0.018), previous metastatic sites other than lung (p < 0.001) and DFI < 24 months (p = 0.007). Our results support the evidence that surgical indication confirms its important role in stage IV melanoma with resectable pulmonary metastases, and selected patients can still benefit from pulmonary metastasectomy in terms of overall cancer specific survival. Furthermore, the novel systemic therapies may contribute to prolonged survival after systemic recurrence following pulmonary metastasectomy. Patients with long DFI, radial growth melanoma phase and no site of metastatization other than lung seem to be the best candidate cases for lung metastasectomy; however, to drive stronger conclusions, further studies evaluating the role of metastasectomy in patients with iPmMM are needed.

Enhanced recovery after laparoscopic cholecystectomy: A single-center experience

Objective:The role of Eintraoperative joint organ removal or transit abdominal surgery recovery after surgery (ERAS) in reducing hospital stay time and perioperative hospitalization costs have been proven. However, most studies have been carried out in areas rich in medical resources. In this study, we evaluated the safety and efficacy of ERAS compared with traditional perioperative period care for laparoscopic cholecystectomy(LC) in areas poor in medical resources in China. Methods:A randomized controlled trial on laparoscopic cholecystectomy was conducted at The People's Hospital ofFengqing from July 2020 to March 2021. Patients were randomly divided into an ERAS group and a traditional care group. The main outcome was the length of hospital stay after surgery. The secondary outcomes included hospitalization costs and visual analogue scale (VAS) scores for postoperative pain, first exhaust time, and first semi-liquid diet time after surgery. The ERAS group was provided with perioperative education, nutritional support, preoperative 2 h oral carbohydrates, restricted rehydration, intraoperative insulation, no drainage tubes, wound hemp, early mobilization postoperative nausea and vomiting (PONV) prevention and multi-modal analgesia, early activity. Results: The study was conducted on a total of 140 patients with 70 patients each in the ERAS group and traditional care groups. In the ERAS group, Thelength of hospital stay after surgery was shorter (4.06 vs.4.61 days, P&lt;0.05), the average hospitalization cost (CNY 7900 vs. 8470, P&lt;0.05),and VAS score (3.10 vs. 3.57 points, compared to the eraser group P&lt;0.001) was lower, the first exhaust time was shorter (12.2 vs. 14.2 hours, P&lt;0.001),thefirst semi-liquid diet time after surgery was shorter(14.5 vs. 16.8 hours, P&lt;0.001), and the incidence of major postoperative complications was lower (bile leakage, postoperative bleeding, bile duct damage) (0% vs. 12.9%, P&lt;0.05). No significant difference in surgery time (57.8 vs. 54.6 min, P&gt;0.05) was observed between the two groups. Conclusion: Even in areas poor in medical resources in China, the use of the ERAS concept for LC surgery can reduce the length of hospital stay, cut down the cost of hospitalization, and lessen the pain of patients after surgery and accelerate postoperative recovery.

Sarcopenia negatively affects postoperative short-term outcomes of patients with non-cirrhosis liver cancer

BackgroundLiterature review have shown that sarcopenia substantially alters the postoperative outcomes after liver resection for malignant tumors. However, these retrospective studies do not distinguish cirrhotic and non-cirrhotic liver cancer patients, nor combine the assessment of muscle strength in addition to muscle mass. The purpose of this study is to study the relationship between sarcopenia and short-term outcomes after hepatectomy in patients with non-cirrhotic liver cancer.MethodsFrom December 2020 to October 2021, 431 consecutive inpatients were prospectively enrolled in this study. Muscle strength and mass were assessed by handgrip strength and the skeletal muscle index (SMI) on preoperative computed tomographic scans, respectively. Based on the SMI and the handgrip strength, patients were divided into four groups: group A (low muscle mass and strength), group B (low muscle mass and normal muscle strength), group C (low muscle strength and normal muscle mass), and group D (normal muscle mass and strength). The main outcome was major complications and the secondary outcome was 90-d Readmission rate.ResultsAfter strictly exclusion, 171 non-cirrhosis patients (median age, 59.00 [IQR, 50.00–67.00] years; 72 females [42.1%]) were selected in the final analysis. Patients in group A had a statistically significantly higher incidence of major postoperative complications (Clavien–Dindo classification ≥ III) (26.1%, p = 0.032), blood transfusion rate (65.2%, p < 0.001), 90-day readmission rate (21.7%, p = 0.037) and hospitalization expenses (60,842.00 [IQR, 35,563.10–87,575.30], p < 0.001) than other groups. Sarcopenia (hazard ratio, 4.21; 95% CI, 1.44–9.48; p = 0.025) and open approach (hazard ratio, 2.56; 95% CI, 1.01–6.49; p = 0.004) were independent risk factors associated with major postoperative complications.ConclusionsSarcopenia is closely related to poor short-term postoperative outcomes in non-cirrhosis liver cancer patients and the assessment that combines muscle strength and muscle mass can simply and comprehensively identify it.Trial registrationClinicalTrials.gov identifiers NCT04637048. (19/11/2020).

Complications associated with costal cartilage harvest in pediatric laryngotracheal reconstruction.

We aimed to determine the rate of complications associated with autologous costal cartilage graft harvest for pediatric laryngotracheal reconstruction (LTR). Secondarily, we sought to identify risk factors associated with the harvest of autologous costal cartilage, as well as evaluate management strategies. An electronic database search of Ovid MEDLINE, Ovid EMBASE, and PubMed was completed for articles pertaining to complications in autologous costal cartilage harvest for pediatric LTR. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The study characteristics, operative information, and patient demographics were collected. The data concerning postoperative complications, risk factors, and management strategies were collected and analyzed for patterns. A total of 31 manuscripts representing 745 patients were included for analysis. The reported donor site complications included pneumothorax (n=13, 1.74%), pleural tear (n=5, 0.67%), infection (n=8, 1.07%), and scar-related problems (n=2, 0.26%). There were no reported cases of seroma, persistent pain, or chest wall deformity. Only five studies discussed the management of donor site complications, with intervention in 11 (39.28%) patients including chest tube drainage and steroid injection. There is significant variability in the literature regarding complication rates in autologous costal cartilage harvest for pediatric LTR. The incidence of major postoperative complications is low and supports the use of autologous costal cartilage as graft material for pediatric LTR. NA.

Posterior Fossa Midline Epidermoid Tumors: Role of the Inferior Medullary Velum and a Proposed New Imaging Classification.

Posterior fossa midline epidermoid tumors (PFMETs) include the epidermoid tumors of the cisterna magna (CM) and fourth ventricle (FV). To report tumor epicenter-based classification of PFMETs and its clinical and surgical implications with outcome. On retrospective analysis of operated cases of intracranial epidermoid tumors, 19 (N = 19) patients having tumor epicenter within FV, CM, or both were included. Cerebellopontine and prepontine cistern epidermoid were excluded. Tumor location was decided based on preoperative MRI and intraoperative findings. Major complication was defined as new onset or worsening of cranial nerve (CN) deficit, sensory motor impairment, or tracheostomy. The mean (±SD) age of the patients was 42.0 ± 11.6 years (range 25-61 years), with no sex predilection (male:female: 1:0.9). The most common symptoms were cerebellar dysfunction, headache, vomiting, and diplopia. Common CNs affected were VII, V, lower cranial nerve, and VI. The PFMETs were classified based on tumor epicenter as type 1 (tumor epicenter in CM, n = 4/21.1%), type 2 (FV, n = 5/26.3%), and type 3 (involved CM and FV, n = 10/52.6%). Type 2 tumors had a higher incidence of raised intracranial pressure and only facial nerve palsy as preoperative CN deficit. Type 1 tumors had the least incidence of postoperative major complications. Type 3 tumors were the largest and had a greater incidence of brainstem adhesion and postoperative complications. The tumor size, duration of symptoms, and patient age were higher in patients with brainstem adhesion (5.3 ± 1.0 cm, 21 ± 16 months, 44.1 ± 9.2 years) as against its absence (4.8 ± 1.3 cm, 11.2 ± 7.3 months, 38.2 ± 11.7 years). Inferior medullary velum and tela choroidea have a critical role in tumorogenesis, tumor extension, and brainstem adhesion. PFMETs can be classified into 3 subtypes based on tumor epicenter having clinical and surgical implications. Less aggressive dissection and near total excision in the presence of brainstem adhesion yield favorable outcomes.

Clinicopathological Features and Treatment Outcome of Patients with Gastric Cancer in Lagos: Is the Outlook Getting Better?

Gastric cancer (GC) is an important cause of morbidity and mortality in Nigeria. Significant advances in the management of GC in South-West Nigeria occurred in the last three decades. This was a retrospective comparative study of patients with GC that presented at our tertiary hospital in the last three decades. Information on clinicopathological features and treatment outcome were analysed. Data of two consecutive periods; 1991-2004 (Group I) and 2005-2018 (Group II) were compared. Ninety-one patients were studied; Group I (47 patients), Group II (44 patients). The mean age was 56.4 ± 12.7 years and male-to-female ratio was 1.8 to 1.0. The predominant symptoms were epigastric pain in 81(89.0%) (43 vs. 38) and weight loss in 63(69.2%) (32 vs. 31), whereas the signs were epigastric tenderness in 44(46.1%) (24 vs. 20) and epigastric mass in 42(46.1%) (26 vs. 16). The overall mean duration of symptom was 12.3 ± 16.9 months. Barium meal diagnosed GC in 29(61.7%) patients in Group I vs. 4(9.1%) patients in Group II. Conversely, endoscopy diagnosed GC in 23(48.9%) patients in Group I vs. 37(84.1%) patients in Group II. Operations undertaken included palliative subtotal gastrectomy 26(28.6%), potentially curative subtotal gastrectomy 15(16.5%) and non-resectional surgeries in 27(29.7%) patients. The overall incidence of major post-operative complications was 33%. Thirty-nine (42.8%) of the studied patients were lost to follow up. The median postoperative survival for Groups I and II patients was 22 weeks and 58 weeks, P = 0.012, respectively. The outcome of management of patients with GC at our tertiary hospital has improved modestly in the past three decades. Patients are still presenting late with very advanced disease.

Effect of personalized perioperative blood pressure management on postoperative complications and mortality in high-risk patients having major abdominal surgery: protocol for a multicenter randomized trial (IMPROVE-multi)

BackgroundIntraoperative hypotension is common in patients having non-cardiac surgery and is associated with serious complications and death. However, optimal intraoperative blood pressures for individual patients remain unknown. We therefore aim to test the hypothesis that personalized perioperative blood pressure management—based on preoperative automated blood pressure monitoring—reduces the incidence of a composite outcome of acute kidney injury, acute myocardial injury, non-fatal cardiac arrest, and death within 7 days after surgery compared to routine blood pressure management in high-risk patients having major abdominal surgery.MethodsIMPROVE-multi is a multicenter randomized trial in 1272 high-risk patients having elective major abdominal surgery that we plan to conduct at 16 German university medical centers. Preoperative automated blood pressure monitoring using upper arm cuff oscillometry will be performed in all patients for one night to obtain the mean of the nighttime mean arterial pressures. Patients will then be randomized either to personalized blood pressure management or to routine blood pressure management. In patients assigned to personalized management, intraoperative mean arterial pressure will be maintained at least at the mean of the nighttime mean arterial pressures. In patients assigned to routine management, intraoperative blood pressure will be managed per routine. The primary outcome will be a composite of acute kidney injury, acute myocardial injury, non-fatal cardiac arrest, and death within 7 days after surgery.DiscussionOur trial will determine whether personalized perioperative blood pressure management reduces the incidence of major postoperative complications and death within 7 days after surgery compared to routine blood pressure management in high-risk patients having major abdominal surgery.Trial registrationClinicalTrials.gov NCT05416944. Registered on June 14, 2022.