Incidence Of Severe Postoperative Complications Research Articles

411. IMPACT OF FEEDING ADJUNCTS AND RADIOLOGICAL SARCOPENIA ON OUTCOMES IN NEO-ADJUVANT TREATED OESOPHAGEAL CANCER PATIENTS

Abstract Introduction Nutritional management plays a pivotal role in the care of patients with oesophageal cancer, particularly for those presenting with complete dysphagia, which poses a significant management challenge. Establishing adequate nutrition is not only a prerequisite for initiating neo-adjuvant treatment in cases of potentially curable disease but is also crucial for patient survival and quality of life. Additionally, emerging evidence suggests that sarcopenia, significantly predicts post-operative complications following oesophageal surgery. Our study aims to evaluate the impact of feeding adjuncts during neo-adjuvant treatment on outcomes, including post-operative complications, and to investigate the prevalence and implications of radiological sarcopenia in these patients. Methods Data from the Northern Oesophago-Gastric Cancer Unit database was used to identify patients diagnosed with oesophageal cancer and discussed at the multidisciplinary team (MDT) meetings from 2017 to 2021. The focus was on those deemed curable with planned neo-adjuvant treatment followed by surgery. Through MDT notes review, patients were identified that required feeding adjuncts prior to surgery. Demographics, tumour characteristics, treatment modalities, hospital stay length, complication rates, and survival outcomes were collected. Radiological sarcopenia was evaluated at initial staging and re-staging computed tomography (CT) scans. Results 353 patients were included; 15 required pre-operative feeding adjuncts. This subgroup was predominantly male (73%), with a higher proportion having squamous cell carcinoma (SCC) (34% V 17%). Progression to surgery was lower in the adjunct group (73% V 87%, p=0.11). Post-operative hospital stay and one-year survival rates were comparable between groups. The adjunct group had a higher incidence of severe post-operative complications (50% Vs 28% Clavien-Dindo grade ≥3, p=0.08). Radiological sarcopenia was higher in the adjunct group (70% Vs 52%, p=0.18), with no cases of sarcopenia reversal after re-staging in the adjunct group, versus 9% in the non-adjunct group. Conclusion These findings highlight an association between complete dysphagia in patients with potentially curable oesophageal cancer and increased rates of post-operative complications and pre-operative radiological sarcopenia. Notably, these patients are more likely to be female and have SCC. The data underscore the critical need for diligent monitoring and nutritional support for patients requiring feeding adjuncts in the neo-adjuvant phase, emphasizing the broader implications of nutritional status on surgical outcomes and overall patient care in oesophageal cancer management.

Perioperative Changes in Plasma Nitrite and IL-6 Levels Predict Postoperative Atrial Fibrillation (POAF) and Acute Kidney Injury (AKI) after Cardiac Surgery.

Background: Postoperative atrial fibrillation (POAF) and acute kidney injury (AKI) are common yet significant complications after cardiac surgery, with incidences of up to 40% for each. Here, we assessed plasma nitrite and serum interleukin-6 (IL-6) levels before and after cardiac surgery to quantify the extent to which oxidative stress and inflammation contribute to POAF and AKI occurrence. Methods: We prospectively enrolled 206 cardiac surgical patients. Plasma nitrite and serum IL-6 levels were determined preoperatively and at 24 h, 48 h and 72 h postoperatively. The patients had continuous EKG monitoring for occurrence of POAF, while daily serum creatinine was measured for determination of stage 1 + AKI. Results: Postoperatively, 78 (38%) patients experienced AF, and 47 (23%) patients experienced stage 1 + AKI. POAF analysis: Age, ACE-inhibitor use, valve surgery and percent change in baseline plasma nitrite at 24 h postoperatively were associated with POAF in multiple logistic regression analysis. The inclusion of this new biomarker significantly improved the POAF prediction model (AUC 0.77 for clinical risk factors alone, to AUC 0.81). AKI analysis: A history of diabetes mellitus was associated with AKI in multiple logistic regression analysis, and the addition of preoperative IL-6 levels improved the prediction model for AKI occurrence (AUC 0.69 to AUC 0.74). Conclusions: We previously observed selective upregulation of NADPH oxidase isoform 4 (NOX4) in patients with AF, a critical causal role of NOX4 for AF in zebrafish and a robust inhibitory effect of nitric oxide (NO) on NOX4. Our data innovatively demonstrate that a reduction in circulating nitrite levels, likely implicative of elevated NOX4-mediated oxidative stress, independently associates with POAF and improves POAF prediction, whereas the inclusion of circulating IL-6 levels improves the prediction model for AKI. Therefore, therapeutic strategies to mitigate these pathophysiological sequalae of surgical stress may reduce the incidence of severe postoperative complications of POAF and AKI.

Feasibility of transperineal minimal invasive surgery when performing sacrectomy for advanced primary and recurrent pelvic malignancies.

This study aimed to clarify the efficacy and safety of minimally invasive transabdominal surgery (MIS) with transperineal minimal invasive surgery (tpMIS) for sacrectomy in advanced primary and recurrent pelvic malignancies. Using a prospectively collected database, we retrospectively analyzed the clinical, surgical, and pathological outcomes of MIS with tpMIS for sacrectomies. Surgery was performed between February 2019 and May2023. The median follow-up period was 27months (5-46months). Fifteen consecutive patients were included in this analysis. The diagnoses were as follows: recurrent rectal cancer, n = 11 (73%); primary rectal cancer, n = 3 (20%); and recurrent ovarian cancer, n = 1 (7%). Seven patients (47%) underwent pelvic exenteration with sacrectomy, six patients (40%) underwent abdominoperineal resection (APR) with sacrectomy, and two patients (13%) underwent tumor resection with sacrectomy. The median intraoperative blood loss was 235ml (range 45-1320ml). The postoperative complications (Clavien-Dindo grade ≥ 3a) were graded as follows: 3a, n = 6 (40%); 3b, n = 1 (7%); and ≥ 4, n = 0 (0%). Pathological examinations demonstrated that R0 was achieved in 13 patients (87%). During the follow-up period, two patients (13%) developed local re-recurrence due to recurrent cancer. The remaining 13 patients (87%) had no local disease. Fourteen patients (93%) survived. Although the patient cohort in this study is heterogeneous, MIS with tpMIS was associated with a very small amount of blood loss, a low incidence of severe postoperative complications, and an acceptable R0 resection rate. Further studies are needed to clarify the long-term oncological feasibility.

Machine learning models including preoperative and postoperative albumin-bilirubin score: short-term outcomes among patients with hepatocellular carcinoma

BackgroundWe sought to assess the impact of various perioperative factors on the risk of severe complications and post-surgical mortality using a novel maching learning technique. MethodsData on patients undergoing resection for HCC were obtained from an international, multi-institutional database between 2000 and 2020. Gradient boosted trees were utilized to construct predictive models. ResultsAmong 962 patients who underwent HCC resection, the incidence of severe postoperative complications was 12.7% (n = 122); in-hospital mortality was 2.9% (n = 28). Models that exclusively used preoperative data achieved AUC values of 0.89 (95%CI 0.85 to 0.92) and 0.90 (95%CI 0.84 to 0.96) to predict severe complications and mortality, respectively. Models that combined preoperative and postoperative data achieved AUC values of 0.93 (95%CI 0.91 to 0.96) and 0.92 (95%CI 0.86 to 0.97) for severe morbidity and mortality, respectively. The SHAP algorithm demonstrated that the factor most strongly predictive of severe morbidity and mortality was postoperative day 1 and 3 albumin-bilirubin (ALBI) scores. ConclusionIncorporation of perioperative data including ALBI scores using ML techniques can help risk-stratify patients undergoing resection of HCC.

Outcomes of secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer progressed after prior poly (adenosine diphosphate-ribose) polymerase inhibitors: A retrospective cohort study

ObjectiveTo evaluate the impact of previous poly (adenosine diphosphate-ribose) polymerase (PARP) inhibitor therapy on the effectiveness of secondary cytoreductive surgery (SCS) in patients with platinum-sensitive recurrent ovarian cancer (PSROC). MethodsWe identified patients with PSROC who underwent SCS at the Cancer Hospital, Chinese Academy of Medical Science, between January 2010 and December 2022. Postoperative complications within 30 days were categorized using the Accordion Severity Grading System. The Kaplan‒Meier method was used to estimate both overall survival (OS) and progression-free survival (PFS), and multivariate analysis was used to identify independent prognostic factors. ResultsOf the 265 patients included, 39 received prior PARP inhibitor therapy (Group A), and 226 did not (Group B). The rates of complete resection after SCS did not significantly differ between the two groups (79.5 % for Group A vs. 81.0 % for Group B; p = 0.766). As of December 2023, Group A exhibited a significantly shorter median PFS (14.2 months) than Group B (22.5 months; p = 0.002). Furthermore, the 3-year OS rate was lower in Group A (72.5 %) than in Group B (82.7 %; p = 0.015). The incidence of severe postoperative complications was comparable between Groups A and B (7.7 % vs. 1.8 %; p = 0.061). Multivariate analysis revealed that prior PARP inhibitor therapy significantly reduced the median PFS (hazard ratio (HR) = 4.434; p = 0.021) and OS (HR = 2.076; p = 0.010). ConclusionsSCS for PSROC demonstrated reduced efficacy in patients previously treated with PARP inhibitors compared to those without prior PARP inhibitor treatment.

Impact of severe postoperative complications on the prognosis of older patients with colorectal cancer: a two-center retrospective study

BackgroundThe occurrence of postoperative complications may affect short-term outcomes and prognosis of patients with various malignancies. However, the prognostic impact of these complications in older patients with colorectal cancer (CRC) remains unclear. Therefore, this study aimed to investigate the impact of severe postoperative complications on the oncological outcomes of older (aged ≥ 80 years) and non-older (aged < 80 years) patients with CRC.MethodsWe retrospectively analyzed 760 patients with stage I–III CRC who underwent curative surgery in two institutions between 2013 and 2019. The patients were categorized into older (aged ≥ 80 years, 191 patients) and non-older (aged < 80 years, 569 patients) groups. Short- and long-term outcomes were compared between the two groups.ResultsThe incidence of severe postoperative complications did not differ between the two groups (p = 0.981). Cancer-specific survival (CSS) was significantly worse in older patients with severe complications than in those without severe complications (p = 0.007); meanwhile, CSS did not differ between the non-older patients with severe complications and those without severe complications. Survival analysis revealed that the occurrence of severe postoperative complications was an independent prognostic factor for CSS in older patients (hazard ratio = 4.00, 95% confidence interval: 1.27–12.6, p = 0.017).ConclusionCRC surgery can be safely performed in older and non-older patients. Moreover, the occurrence of severe postoperative complications might more strongly affect the prognosis of older patients than that of non-older patients.

Robotic Versus Open Pancreatoduodenectomy With Vein Resection and Reconstruction: A Propensity Score-Matched Analysis.

This study aimed to compare robotic pancreatoduodenectomy with vein resection (PD-VR) based on the incidence of severe postoperative complications (SPC). Robotic pancreatoduodenectomy has been gaining momentum in recent years. Vein resection is frequently required in this operation, but no study has compared robotic and open PD-VR using a matched analysis. This was an intention-to-treat study designed to demonstrate the noninferiority of robotic to open PD-VR (2011-2021) based on SPC. To achieve a power of 80% (noninferiority margin:10%; α error: 0.05; ß error: 0.20), a 1:1 propensity score-matched analysis required 35 pairs. Of the 151 patients with PD-VR (open = 115, robotic = 36), 35 procedures per group were compared. Elective conversion to open surgery was required in 1 patient with robotic PD-VR (2.9%). One patient in both groups experienced partial vein thrombosis. SPC occurred in 7 (20.0%) and 6 patients (17.1%) in the robotic and open PD-VR groups, respectively (P = 0.759; OR: 1.21 [0.36-4.04]). Three patients died after robotic PD-VR (8.6%) and none died after open PD-VR (P = 0.239). Robotic PD-VR was associated with longer operative time (611.1 ± 13.9 minutes vs 529.0 ± 13.0 minutes; P < 0.0001), more type 2 vein resection (28.6% vs 5.7%; P = 0.0234) and less type 3 vein resection (31.4% vs 71.4%; P = 0.0008), longer vein occlusion time (30 [25.3-78.3] minutes vs 15 [8-19.5] minutes; P = 0.0098), less blood loss (450 [200-750] mL vs 733 [500-1070.3] mL; P = 0.0075), and fewer blood transfusions (intraoperative: 14.3% vs 48.6%; P = 0.0041) (perioperative: 14.3% vs 60.0%; P = 0.0001). In this study, robotic PD-VR was noninferior to open PD-VR for SPC. Robotic and open PD-VR need to be compared in randomized controlled trials.

Association of clonal haematopoiesis with severe postoperative complications in patients undergoing radical oesophagectomy

BackgroundClonal haematopoiesis (CH) is an age-associated clonal expansion of blood cells driven by leukaemia-associated somatic mutations. Although CH has been reported to be a risk factor for leukaemia and a number of non-haematopoietic diseases, its role in perioperative medicine remains unexplored. MethodsThis was a single-centre, prospective, observational study. Patients undergoing radical oesophagectomy were enrolled, and peripheral blood samples were collected for DNA sequencing. Patients with haematopoietic somatic mutations (variant allele frequencies ≥1%) in the DNMT3A gene, TET2 gene, or both were defined as CH carriers. The primary outcome was the incidence of severe postoperative complications (Clavien–Dindo classification ≥3). The secondary outcomes included the major types of postoperative complications, mortality, and other common perioperative variables. ResultsClonal haematopoiesis was found in 21.2% (33/156) of the patients (mean age: 66 yr [range: 26–79 yr]; 83% males). Some 14/33 (42.4%) patients with CH had severe postoperative complications, compared with patients without CH carriers (28/123 [22.8%]; P=0.024). Multivariable logistic regression analysis showed that CH was associated with an increased risk of developing severe postoperative complications (odds ratio, 3.63; 95% confidence interval, 1.37–9.66; P=0.010). Among the major postoperative complications, the incidence of pulmonary complications was significantly higher in the patients with CH than in those without CH (15 in 33 [45.5%] vs 30 in 123 [24.4%], P=0.018). ConclusionsClonal haematopoiesis was associated with a higher incidence of severe postoperative complications in patients undergoing radical oesophagectomy, suggesting that clonal haematopoiesis can play an important role in perioperative medicine. Clinical trial registrationChiCTR2100044175 (Chinese Clinical Trial Registry, http://www.chictr.org.cn/showproj.aspx?proj=123193).

Association of Malnutrition Diagnosed Using Global Leadership Initiative on Malnutrition Criteria with Severe Postoperative Complications After Gastrectomy in Patients with Gastric Cancer.

Background: The purpose of this study was to investigate the relationship between malnutrition assessed by the Global Leadership Initiative on Malnutrition (GLIM) criteria and the occurrence of severe postoperative complications (SPCs) after gastrectomy in patients with gastric cancer. Methods: A total of 220 patients with gastric cancer were included in this retrospective study. According to the GLIM criteria, the first step was to use the Nutrition Risk Screening Score 2002 to conduct nutritional risk screening for patients and the second step was to diagnose and grade the severity of malnutrition in patients at risk of malnutrition. According to the Clavien-Dindo classification system, SPCs were defined as C-D Grade IIIa or higher. Results: Overall, 66 (30.0%) patients were diagnosed with malnutrition, including 32 (14.5%) with moderate malnutrition and 34 (15.5%) with severe malnutrition. The incidence of SPCs was 14.5%, and the most frequent postoperative event was anastomotic leakage. In the multivariate regression analysis, malnutrition was considered an independent risk factor for SPCs (P < .001). After adjusting for various factors, the grading association remained statistically significant. Compared with patients with normal nutrition, patients with moderate and severe malnutrition have a nearly 15-fold (OR = 15.682, 95% CI: 4.481-54.877, P < .001) and 20-fold (OR = 20.554, 95% CI: 5.771-73.202, P < .001) increased risk of developing SPCs, respectively. Conclusions: Malnutrition assessed by GLIM was an independent risk factor for SPCs in gastric cancer patients. Therefore, early identification of malnourished patients is crucial for timely implementation of nutritional treatment and reducing the occurrence of postoperative complications.

Impact of Sarcopenic Obesity on Severe Postoperative Complications in Patients with Gastric Cancer Undergoing Gastrectomy

Introduction: Several studies have indicated that sarcopenia affects the short- and long-term outcomes of cancer patients, including those with gastric cancer. In recent years, sarcopenic obesity and its effects have been reported in cancer patients. This study aimed to evaluate the impact of sarcopenic obesity on postoperative complications in patients with gastric cancer undergoing gastrectomy. Methods: This single-center, retrospective study included 155 patients who underwent curative gastrectomy for gastric cancer from January 2015 to July 2021. Sarcopenia was defined by the psoas muscle index (<6.36 cm²/m² in men and <3.92 cm²/m² in women), which measures the iliopsoas muscle area at the lumbar L3 level using computed tomography. Obesity was defined by body mass index (≥25). Patients with both sarcopenia and obesity were defined as the sarcopenic obesity group and others as the non-sarcopenic obesity group. Severe postoperative complications were defined as Clavien-Dindo classification grade IIIa or higher. Results: Of the 155 patients, 26 (16.8%) had sarcopenic obesity. The incidence of severe postoperative complications was significantly higher in the sarcopenic obesity group (30.8% vs. 10.9%; p = 0.014). Multivariate analysis indicated that sarcopenic obesity was an independent risk factor for severe postoperative complications (odds ratio, 3.950; 95% confidence interval, 1.390–11.200; p = 0.010). Conclusion: Sarcopenic obesity is an independent risk factor for severe postoperative complications.

Prospective minimally invasive pancreatic resections from the IGOMIPS registry: a snapshot of daily practice in Italy on 1191 between 2019 and 2022

This retrospective analysis of the prospective IGOMIPS registry reports on 1191 minimally invasive pancreatic resections (MIPR) performed in Italy between 2019 and 2022, including 668 distal pancreatectomies (DP) (55.7%), 435 pancreatoduodenectomies (PD) (36.3%), 44 total pancreatectomies (3.7%), 36 tumor enucleations (3.0%), and 8 central pancreatectomies (0.7%). Spleen-preserving DP was performed in 109 patients (16.3%). Overall incidence of severe complications (Clavien–Dindo ≥ 3) was 17.6% with a 90-day mortality of 1.9%. This registry analysis provided some important information. First, robotic assistance was preferred for all MIPR but DP with splenectomy. Second, robotic assistance reduced conversion to open surgery and blood loss in comparison to laparoscopy. Robotic PD was also associated with lower incidence of severe postoperative complications and a trend toward lower mortality. Fourth, the annual cut-off of ≥ 20 MIPR and ≥ 20 MIPD improved selected outcome measures. Fifth, most MIPR were performed by a single surgeon. Sixth, only two-thirds of the centers performed spleen-preserving DP. Seventh, DP with splenectomy was associated with higher conversion rate when compared to spleen-preserving DP. Eighth, the use of pancreatojejunostomy was the prevalent reconstruction in PD. Ninth, final histology was similar for MIPR performed at high- and low-volume centers, but neoadjuvant chemotherapy was used more frequently at high-volume centers. Finally, this registry analysis raises important concerns about the reliability of R1 assessment underscoring the importance of standardized pathology of pancreatic specimens. In conclusion, MIPR can be safely implemented on a national scale. Further analyses are required to understand nuances of implementation of MIPR in Italy.

Safety and Efficacy of Neoadjuvant SABR in Pancreatic Cancer: Effect of Magnetic Resonance Imaging–Guided Respiratory-Gated Adaptive Radiation Therapy

We aimed to evaluate the safety and efficacy of neoadjuvant SABR using magnetic resonance imaging-guided respiratory-gated adaptive radiation therapy (MRgRg-ART) in pancreatic cancer. We performed a single-institution retrospective review in patients with pancreatic cancer who underwent neoadjuvant SABR followed by surgical resection. After neoadjuvant chemotherapy, those considered resectable by the multidisciplinary team received SABR over 5 consecutive days using MRgRg-ART. Factors associated with severe postoperative complications (Clavien-Dindo grade ≥III) and prognostic factors for overall survival were analyzed. Sixty-two patients were included in the analysis, with a median follow-up of 10.3 months. The median prescribed dose to the planning target volume was 50 Gy. Fifty-two (85.3%) patients underwent R0 resection, and 11 (18.0%) experienced severe postoperative complications. No factors were associated with the incidence of severe postoperative complications. There were 3 cases of locoregional recurrence, resulting in a 12-month local control rate of 93.1%. Elevated postoperative carbohydrate antigen 19-9 was significantly associated with poor overall survival in the multivariate analysis (P=.037). Neoadjuvant SABR with 50 Gy using MRgRg-ART delivered to pancreatic cancer resulted in a notable survival outcome with acceptable toxicities. Further studies are warranted to investigate the long-term effects of this method.

Impact of preoperative mitral regurgitation on left ventricular assist device patients: propensity score-matched analysis of the EUROMACS dataset.

Mitral regurgitation (MR) is frequently observed in patients undergoing left ventricular assist device implantation. We investigated the impact of preoperative MR on left ventricular assist device patients. A retrospective propensity score-matched analysis of adult patients enrolled in the EUROMACS registry between 1 January 2011 and 30 November 2021 was performed. Patients were divided into 2 groups according to the grade of preoperative MR: none-to-mild (MR 0-II) or moderate-to-severe (MR III-IV). Following 1:1 propensity score matching, each group consisted of 914 patients. Incidence of postoperative temporary right ventricular support, reoperation for bleeding and dialysis was similar. MR III-IV demonstrated shorter median intensive care unit stay [14 days (6; 27.8) vs 10 days (5; 22), P = 0.004] and ventilation time [72 h (22, 320) vs 31 h (18, 150), P < 0.001]. Mortality was lower for MR III-IV patients [subdistribution hazard ratio: 0.66, 95% confidence interval (CI): 0.59-0.73, P < 0.001]. The 1-year survival was 68.1% (95% CI: 65.1-71.3%) in MR 0-II and 75% (95% CI: 72.1-78%) in MR III-IV. A lower incidence of total complications [odds ratio (OR): 0.93 (0.89-0.98), P = 0.003] and trend towards a lower risk of neurological dysfunction (subdistribution hazard ratio: 0.79; 95% CI: 0.61-1.01, P = 0.063) and sustained ventricular tachycardia [OR: 0.93 (0.54-1.03), P = 0.074] were demonstrated for MR III-IV. The risk of fatal stroke and pump thrombosis was similar. Moderate-to-severe MR in patients undergoing left ventricular assist device implantation is associated with better mid-term survival and lower incidence of total major adverse events and complications. The incidence of severe postoperative complications including fatal stroke and device thrombosis was similar.

Laparoscopic Repair Modality of Perforated Peptic Ulcer: Less Is More?

Perforation, per se, presents the most serious complication of peptic ulcer disease with a mortality rate that cannot be underestimated. Surgery is the only treatment option, which can be performed laparoscopically or via conventional laparotomy. The present study aimed to compare the short-term outcomes of laparoscopy and laparotomy techniques in the surgical treatment of peptic ulcer perforation. A retrospective study design was structured to compare the perioperative and short-term postoperative outcomes of 102 patients who had undergone laparoscopic and conventional repair of the perforated peptic ulcer over a six-year interval (January 1, 2016, to December 31, 2021). Of these, 44 (43.1%) had undergone laparoscopic repair while 58 (56.9%) had surgical repair via conventional laparotomy. The operative time and length of hospital stay were comparable in both subgroups (p=0.984 and p =0.585). Nevertheless, 30-day postoperative morbidity was significantly higher in the open surgery subgroup (75.9% vs. 59.1%, p= 0.032). The risk of relaparotomy was similar in both study subgroups; however, suture dehiscence as a reason for surgical revision was significantly more frequent in the laparoscopic subgroup (13.6% vs 3.4%). Of note, the mortality rate in the laparoscopic group of patients was 13.6%, and in the laparotomy group 41.4%. The laparoscopic approach to peptic ulcer perforation is the procedure of choice for low-risk patients. Conventional surgery seems to be associated with a significantly higher incidence of severe postoperative complications and mortality. However, the higher mortality in these patients is probably related to their worse initial clinical condition.

Analysis of early severe postoperative complications and risk factors in 4255 patients who underwent bariatric and metabolic surgery in a single cente

Objective: To analyze the incidence of early severe complications following bariatric and metabolic surgery and the experience of their diagnosis, treatment, and risk factors. Methods: In this retrospective observational study, the clinical data of 4255 patients who underwent bariatric and metabolic surgery between May 2010 and May 2022 in the Department of Bariatric and Metabolic Surgery of the First Affiliated Hospital of Nanjing Medical University were retrospectively collected. Among these patients, 1125 were male and 3130 were female. The mean age and body mass index (BMI) of the patients at the time of operation were 31.3±4.5 years and 36.5±6.4 kg/m2, respectively. Regarding surgical type, 2397 patients underwent sleeve gastrectomy (SG), 489 underwent Roux-en-Y gastric bypass (RYGB), 1028 underwent sleeve gastrectomy plus jejunojejunal bypass (SG+JJB), and 341 underwent single anastomosis duodenal switch (SADS). The inclusion criteria were patients (1) with a Clavien-Dindo grade of ≥III; (2) who were undergoing SG, RYGB, SG-JJB, or SADS; and (3) who had complete clinical data. The exclusion criteria were patients (1) undergoing revisional surgery and (2) other operations during the bariatric and metabolic surgery. The Clavien-Dindo classification was used to analyze the incidence of early severe postoperative complications and their prognosis. Early severe postoperative complications were defined as Clavien-Dindo ≥ III complications within 30 days after surgery. Meanwhile, multivariate logistic regression model was used to identify risk factors of the complications. Results: Summary of early severe complications following bariatric and metabolic surgery: (1) of the 4255 patients, 22 (12 male and 10 female) exhibited early severe complications (0.52%). The mean age and BMI of these patients were 41.1±9.9 years and 36.9±8.2 kg/m2, respectively. Preoperatively, 7 patients had hypertension, 10 had type 2 diabetes mellitus, 1 had respiratory failure, and 1 had heart failure. The severe complications included 9 patients (0.21%) with grade IIIa, 11 (0.26%) with grade IIIb, 1 (0.02%) with grade IVa, and 1 (0.02%) with grade V complications. The incidences of severe postoperative complications in the different surgical procedures were 0.17% for SG (4/2397), 0.61% for RYGB (3/489), 0.58% for SG+JJB (6/1028), and 2.64% for SADS (9/341). The common severe complications were leakage (0.28%, 12 patients), bleeding (0.14%, 6 patients), and obstruction (0.05%, 2 patients). (2) Management of complications: Grade IIIa complications (including eight patients with leakage and one with severe inflammation) were treated with antibiotics, nasogastric and nutritional tube placements, and CT-guided drainage. For grade IIIa complications, five patients with bleeding were treated with reoperation, and all the patients recovered; four patients with leakage were treated with reoperation, wherein three were converted to RYGB and one patient underwent resuturing of the leakage site; two patients with obstruction were treated with adhesiolysis. The patient with grade IVa complication (including respiratory failure complicated with acid aspiration) was treated in the ICU. For the grade V complication, bleeding in a patient with SG+JJB was treated with reoperation, which confirmed the bleeding of short gastric vessels. Unfortunately, the patient died. (3) Risk factor analysis of early severe complications: univariate analysis detected that sex, age, type 2 diabetes mellitus, operation time, and surgical type were associated with postoperative complications (P<0.05). However, multivariate analysis indicated that an age of ≥31.3 years (odds ratio [OR] = 5.423, 95% confidence interval [CI]: 1.004-29.278, P=0.049) and surgical type (SADS: OR = 19.758, 95%CI: 5.803-67.282, P<0.001; RYGB: OR = 9.752, 95%CI: 2.456-38.723, P=0.001; SG+JJB: OR = 5.706, 95%CI: 1.966- 16.559, P=0.001) were independent risk factors of early severe complications following bariatric and metabolic surgery. Conclusion: Bariatric and metabolic surgery is safe. Its common postoperative complications include leakage, bleeding, and obstruction, which require early detection, diagnosis, and treatment to improve treatment outcomes. Age and surgical type are independent risk factors of early severe complications following bariatric and metabolic surgery.

Comparison of complications and long-term survival after minimally invasive esophagectomy versus open esophagectomy in patients with esophageal cancer and chronic obstructive pulmonary disease

ObjectiveTo compare the complications and long-term survival of esophageal cancer patients with chronic obstructive pulmonary disease (COPD) after minimally invasive esophagectomy (MIE) versus open esophagectomy (OE) using propensity score matching (PSM).MethodsEsophageal cancer patients who underwent esophagectomy at the Thoracic Surgery Department of the First Affiliated Hospital of Hebei North University from January 2010 to December 2018 were retrospectively enrolled. The incidence of postoperative complications and prognosis of the MIE (n = 132) and OE (n = 138) groups were compared. To reduce bias, 1:1 PSM was adopted for the analysis.ResultsThe median disease-free survival (DFS) of the MIE and OE groups were 24 months and 26 months, respectively, and neither group reached median survival. There was no significant difference between the two groups in terms of 3-year DFS and overall survival (OS). The stratification of the patients on the basis of the percentage of estimated forced expiratory volume in the first second (%FEV1) did not result in significant differences in the survival rates. A total of 42 patients (50%) in the MIE group and 55 patients (65.48%) in the OE group experienced complications, and the difference was statistically significant (OR=0.527, 95% CI: 0.283–0.981, P=0.042). The incidence of acute COPD exacerbation (OR=0.213, 95% OR, CI: 0.068–0.666, P=0.004) and pulmonary atelectasis requiring bronchoscopic aspiration (OR=0.232, 95% OR, CI: 0.082–0.659, P=0.004) were significantly higher in the OE versus the MIE group. In addition, the distribution of the various grades of complications also differed significantly between the two groups (P=0.016). While the incidence of minor complications (≤Grade II) was similar in both groups (P=0.503), that of severe complications (≥Grade III) was markedly higher in the OE group (P=0.002) and the Grade-IIIa complications were predominant (P=0.001). The severity of complications was correlated with the postoperative duration of hospital stay in both groups (r=0.187, P=0.015). No significant difference was observed in the incidence of minor complications (≤Grade II) between the two groups following stratification on the basis of %FEV1, whereas severe complications were more frequent in the OE group among patients with %FEV1 between 60% and 70% (P=0.001<0.05).ConclusionThere was no significant difference in the postoperative DFS and OS of esophageal cancer patients with COPD after undergoing MIE or OE. However, MIE significantly reduced the incidence of severe postoperative complications among patients with %FEV1 between 60% and 70%.

Evaluation of clinical outcomes with propensity-score matching for colorectal cancer presenting as an oncologic emergency.

AimOncologic emergencies such as perforation and obstruction associated with colorectal cancer are serious diseases that can lead to sepsis. Peritoneal dissemination and other factors may cause cancer progression and worsen the patients’ long‐term prognosis. In this study, we investigated the effect of colorectal cancer presenting as oncologic emergencies on the patients’ clinical course.MethodsWe performed a retrospective study that included 448 patients with colorectal cancer who underwent primary resection at our institution between January 2014 and December 2018. The primary outcome was overall survival, while secondary outcomes were 30‐day mortality and postoperative complications. Cox regression was used to estimate the hazard ratio (HR) for overall survival.ResultsWe identified 56 patients who presented with oncologic emergencies (OE group) and 392 patients who presented with no emergencies (NE group). Propensity‐score matching yielded 56 patients in the OE group and 55 in the NE group with balanced baseline covariates. We found a strong association between overall survival (OS) and oncologic emergencies (HR = 2.4; 95% confidence interval [CI], 1.1‐5.5). The 30‐day mortality was not significantly different between the OE and NE groups (4% vs 0%, P = .25). The incidence of severe postoperative complications (Clavien‐Dindo classification ≥grade 3) did not differ significantly between the groups (25% vs 15%, P = .23).ConclusionColorectal cancer presenting as an oncologic emergency could be safely operated on without increasing the 30‐day mortality rate and the incidence of severe postoperative complications. However, the long‐term prognosis was poor.

Impact of sarcopenia on surgical and oncologic outcomes of laparoscopic surgery for colorectal cancer

BackgroundThe study aimed to evaluate the impact of sarcopenia on short- and long-term outcomes for laparoscopic colorectal cancer surgery. MethodsStudy participants were 209 patients who underwent laparoscopic surgery for any stage of colorectal cancer between 2016 and 2017. Skeletal muscle indices were calculated with preoperative computed tomography. Patients were divided into sarcopenic and non-sarcopenic groups based on index cut-off values and variables were compared. ResultsThe prevalence of sarcopenia was 41.1%. Sarcopenic patients experienced shorter operative times and a lower incidence of surgical site infections; however, the incidence of severe postoperative complications and readmission were increased for this group. Although the 3-year disease-free survival rate was not statistically different between groups, sarcopenic patients had a significantly worse 3-year overall survival rate compared with than the non-sarcopenic group. ConclusionSarcopenia has both favorable and unfavorable effects on patients who underwent laparoscopic colorectal cancer surgery.

Neoadjuvant chemoradiotherapy for borderline resectable low rectal cancer: short- and long-term outcomes at a single Japanese center.

Rectal cancers pose a threat to the mesorectal fascia or invade neighboring structures or organs. Some tumors are potentially resectable but are likely to be positive at the resection margin for cancer involvement and are thus recognized as "borderline resectable (BR)" tumors. This study aimed to clarify the short- and long-term outcomes of neoadjuvant chemoradiotherapy (nCRT) for BR low rectal cancer at a single Japanese center. Data of 55 patients, who received nCRT followed by BR low rectal cancer surgery between April 2010 and December 2019, were evaluated for the short-term outcomes. The oncological outcomes of 42 patients who underwent surgery between April 2010 and December 2018 were evaluated. Thirty-six (65.5%) patients had cT4 tumors, and 53 (96.4%) patients had a clinical-stage III or IV. Lateral lymph node dissection was performed in 42 (76.4%) patients. The incidence of severe post-operative complications (Clavien-Dindo grade ≥ III) was 18.2%. Fifty-two (94.5%) patients had a pathological negative resection margin. The 3-year overall survival rate, disease-free survival rate, and cumulative incidence of local recurrence were 100%, 70.3%, and 5.3%, respectively. The short- and long-term outcomes of nCRT for BR low rectal cancer were acceptable. In particular, reasonable local control was achieved.

Postoperative Outcomes Associated With Procedural Sedation Conducted by Physician and Nonphysician Anesthesia Providers: Findings From the Prospective, Observational African Surgical Outcomes Study.

There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death. A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included. Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6). The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer.