Complication Index Research Articles

BN SO02 - Cholecystectomy HRG Coding Audit

Abstract Background Incorrect coding practices for elective surgical procedures carry significant financial implications at Trust level. In this project, we aimed to audit the current coding practices pertaining to laparoscopic cholecystectomies performed within the NHS WWL Foundation Trust during November 2021-October 2022 and calculate the financial burden resulting from this. Method A list of 194 patients undergoing a cholecystectomy and their allocated HRG coding at time of discharge was compiled by the coding department. A comorbidity and complication index (CCI) for each of these patients was calculated using the operation note together with hospital and GP records. With this information, the correct HRG coding for each patient was calculated and compared to their allocated coding at discharge to calculate the difference in tariffs generated. Results 69.23% of 194 procedures carried out during the reported time period were coded incorrectly. This amounted to a financial burden of £72,232 lost in potential tariffs, equating to £372.33 per cholecystectomy performed. Commonest CCI of 3 in 29% of patients with corresponding HRG code GA10J Commonest incorrectly allocated coding GA10K denotes a presumed CCI of 0 Conclusion High percentage of incorrectly coded procedures with significant financial implications at Trust level Currenty coding practice often incorrectly presumes a CCI index of 0 with subsequent incorrect GA10K coding. However, the appropriate coding for the vast majority of patients undergoing a laparoscopic cholecystectomy was GA10J. Education and awareness is underway to make improvements at a Trust level before re-auditing of data can commence.

EGS SO13 - Evaluation of Different Surgical Risk Prediction Models in Predicting Morbidity and Mortality in Giant Hiatus and Diaphragmatic Hernia Repairs

Abstract Background Emergency giant hiatus hernia and diaphragmatic hernia repairs are associated with high rates of mortality and morbidity; different studies reported variable outcomes. Accurate risk assessment empowers patients to provide informed consent and also serves as a valuable tool for identifying individuals who may require enhanced postoperative care, such as respiratory support and critical care admission. Various risk prediction tools have been developed to assist clinicians in making decisions to aid in stratifying the risk of surgical management. We aimed to assess the effectiveness of different risk prediction models in predicting mortality and morbidity in this patient cohort. Method Retrospective analysis performed on cases between May, 2010 and January, 2021 in a tertiary adult upper gastro-intestinal centre. The outcomes from the operations were assessed and compared with the predicted morbidity and mortality for different risk prediction models. Including the Surgical Outcome Risk Tool (SORT), the National Emergency Laparotomy Audit (NELA), parsimonious NELA and the American College of Surgeons National Surgical Quality Improvement Programme (ACS-NSQIP). The models were compared using the area under the curve (AUC). Morbidity models included Portsmouth Physiological and Operative Severity Score (P-POSSUM) and the ACS-NSQIP. Morbidity was evaluated by calculating the comprehensive complication index (CCI). Results A total of 108 patients met the criteria and were included in the analysis. Among these 50.9% were females. The median age was 69 (IQR 59-78). The 30-day mortality rate was 6.93% (7 patients), six patients died during the same admission, and one patient died during a re-admission. ACS-NQSIP had the highest predictive power for mortality (AUC = 0.6344), in comparison to NELA (AUC=0.5665), parsimonious NELA (AUC=0.4866) and SORT (AUC = 0.4342). Both ACS-NSQIP and P-POSSUM showed moderate correlation to CCI (rho = 0.489, p<0.001 and 0.446, p<0.001 respectively). Conclusion ACS-NSQIP is a better predictor of both mortality and morbidity in emergency giant hiatus and diaphragmatic hernia repairs when compared to NELA, parsimonious NELA, P-POSSUM and SORT. Interestingly, parsimonious NELA had a lower prediction rate when compared with the older NELA model. ACS-NSQIP may have a role in pre-assessment and consenting of emergency hiatus and diaphragmatic hernia repairs. Multi-centre prospective studies could be used to validate these findings.

Evaluation of Modified Frailty Index for Predicting Postoperative Outcomes After Upper-Extremity Replantation and Revascularisation Procedures.

Upper extremity (UE) replantation and revascularization are challenging surgical procedures, with survival rates being 50% to 90%. Preoperative risk stratification is challenging yet crucial as patients with comorbid conditions face increased complications. This study assesses the predictive value of the modified 5-item frailty index (5-mFI) for postoperative complications in these procedures. A retrospective study was done using the ACS NSQIP database (2011-2021) for UE replantation/revascularization. The 5-mFI score assigned points for comorbidities including pulmonary disease, heart failure, diabetes, hypertension, and functional status (0-5 scale; 1 point to each). 5-mFI scores stratified patients into <2 (low-risk) or ≥2 (high-risk) categories. Of 2,305 patients, the mean age and BMI were 53.13 years and 28.53 kg/m2 respectively. The 5-mFI≥2 cohort experienced higher rates of all-cause complications, systemic complications, unplanned readmissions, and return to the operating room on univariate analysis. There was no significant difference in wound complication rates. Multivariable logistic regression showed that a higher 5-mFI was significantly associated with increased risks of all-cause mild and severe systemic complications. Wound complications, length of stay over 30 days, unplanned readmission, and return to the operating room were higher in high-risk patients, however not statistically significant. 5-mFI is an effective tool for evaluating risk in UE replantation and revascularization, correlating high scores with significantly increased postoperative complications. High-risk patients with 5-mFI≥2 also had more reoperations and readmissions. The use of 5-mFI in preoperative assessments can help personalize management, enhancing patient selection and care quality in these complex reconstructions.

Effect of perioperative rehabilitation exercise on postoperative outcomes in patients aged ≥65 years undergoing gastrointestinal surgery: A multicenter randomized controlled trial

Study objectivesThis study aimed to assess the effect of perioperative rehabilitation exercise, initiated shortly after hospital admission, on postoperative outcomes in elderly patients. DesignA prospective, multicenter, randomized, controlled, open-label, and assessor-blinded clinical trial. SettingHospital wards. PatientsElderly patients (≥65 years, n = 160) scheduled for gastrointestinal surgery between June 2021 and November 2022 were enrolled and randomly assigned to the intervention or control group. InterventionsPatients were divided into two groups base on whether they had received a specific type of exercise program initiated after hospital admission and continued until 30 days after surgery. MeasurementsThe primary outcome was the Comprehensive Complications Index (CCI) measured at 30 days after surgery. Secondary outcomes were the rate of complications, number of complications, patient satisfaction, hospital readmission, postoperative length of stay, gastrointestinal function recovery, postoperative quality of life and psychological status. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted. Main resultsITT analysis showed a significantly lower 30-day CCI in the intervention group (β: -6.31; 95 % Confidence Interval [CI], −11.26 to −1.37, P = 0.013). Compared to controls, the intervention group had a decreased rate of hospital readmission (Odds Ratio: 0.00; 95 % CI, 0.00 to 0.32, P = 0.022), less number of complications (β: -0.57; 95 % CI, −1.03 to −0.11, P = 0.016), as well as lower rate of postoperative anxiety (β: -0.74; 95 % CI, −1.42 to −0.06, P = 0.033) and depression scores (β: -1.13; 95 % CI, −0.97 to −1.30, P = 0.008). Additionally, the intervention group reported higher satisfaction (β: 0.98; 95 % CI, 0.33 to 1.64, P = 0.004) and Euro quality of life-Visual Analogue Scale scores (β: 8.88; 95 % CI, 2.48 to 15.28, P = 0.007). Similar results were found in the PP analysis. ConclusionPerioperative rehabilitation exercise has a positive impact on postoperative complications, quality of life and psychological well-being in elderly patients undergoing gastrointestinal surgery, even when implemented after hospital admission.

A diverse hidradenitis suppurativa cohort: a retrospective cross-sectional study of 13,130 patients from a large US healthcare system database from 1995-2022

BackgroundMost epidemiological studies of hidradenitis suppurativa (HS) have described homogeneous patient populations. ObjectiveTo characterize demographics, modifiable health behaviors, and comorbidities of HS patients within a diverse cohort. MethodsA retrospective cross-sectional study of 13,130 HS patients within a healthcare system was conducted. ResultsA female sex bias of ∼3:1 in all racial/ethnic subgroups was observed. Black/African American (AA) patients had a lower age at HS diagnosis than White patients (37.1 years vs 39.4 years, P<0.001). A higher proportion of Black/AA females than White females with HS had BMI in the obese range (69.9% vs 56.5%; P=0.03). In contrast, fewer Black/African American males with HS had a BMI in the obese range compared to White males (51.4% vs. 61.0%; P<0.001). More Black/AA patients than White patients with HS had congestive heart failure (OR=2.10, CI=1.19-3.78; P<0.05), chronic pulmonary disease (OR=1.34; CI=1.02-1.78; P<0.05), diabetes with chronic complication (OR=1.73; CI=1.16-2.60; P<0.05), renal disease (OR=2.66; CI=1.67-4.34; P<0.05), and Charlson Comorbidity Index score ≥4 (OR=1.67; CI=1.09-2.58; P<0.05). Furthermore, male patients were more likely than female patients to have renal disease (OR=2.62; CI 1.66-4.14; P<0.05). LimitationsA single-center study. ConclusionSubgroups of HS patients had significant differences in demographics, risk factors, and comorbid conditions.

Surgical Outcome in Retroperitoneal Sarcoma Surgery: Accuracy of P-POSSUM, ACS-NSQIP, and Inflammatory Biomarkers Prognostic Index (IBPI) Risk-Calculators for Prediction of Severe and Overall Morbidity.

Retroperitoneal sarcoma often requires comprehensive resection, leading to severe postoperative morbidity. The lack of disease-procedure specific tools for morbidity risk and the questionable accuracy of existing tools (ACS-NSQIP and P-POSSUM) in RPS surgery drove this study to assess these calculators' accuracy. Retrospective analysis of primary RPS cases undergoing surgery at two sarcoma-referral centers was conducted. Predicted morbidity/mortality rates at 90days postsurgery, classified by Clavien-Dindo (CD) and Comprehensive Complication Index (CCI), were compared with observed data. Accuracy was assessed by Brier Score and area under the curve (AUC). Inflammatory Biomarkers Prognostic Index (IBPI) also was tested. A total of 567 patients (median age 62years; 53.6% male) with a median of four resected organs were included. 59% experienced surgical complications by 90 days postoperation, graded CD ≥ 3 in 30.5%, median CCI 20.9, with a mortality rate of 1.6% (8/567). Reoperation was required in 68 of 567 patients (12%). Thirty-day mortality was 1.1%. Severe complications occurred after 30th postoperative day in 3.5% cases. ACS-NSQIP predicted below-average complication for 65.1%, average for 16.9%, and above-average for 18% of patients. P-POSSUM predicted a 66% rate of morbidity and 4% mortality. None of the prediction tools were accurate, with Brier scores ranging 0.155-0.231 and no AUC ≥ 0.7. IBPI accuracy for predicting severe infective complication was low (AUC 0.58, Brier 0.161). The significant morbidity burden after MVR necessitates reliable evaluation, especially in frail patients. Given the limitations of ACS-NSQIP and P-POSSUM, a dedicated prediction tool for perioperative events in RPS candidates for MVR needs urgent development.

Unveiling the intrinsic role of malnutrition in patients with Crohn's disease undergoing major surgery using entropy balancing weighting analysis.

The negative role of malnutrition in patients with Crohn's disease is known; however, many coexisting disease-related factors could cause misinterpretation of the real culprit. This study aimed to describe the role of malnutrition using a novel methodology, entropy balancing. This was a retrospective analysis of consecutive patients undergoing elective major surgery for Crohn's disease, preoperatively screened following the European Society for Clinical Nutrition guidelines. Two-step entropy balancing was applied to the group of malnourished patients to obtain an equal cohort having a null or low risk of malnutrition. The first reweighting homogenised the cohorts for non-modifiable confounding factors. The second reweighting matched the two groups for modifiable nutritional factors, assuming successful treatment of malnutrition. The entropy balancing was evaluated using the d-value. Postoperative results are reported as mean difference or OR, with a 95 % CI. Of the 183 patients, 69 (37·7 %) were at moderate/high risk for malnutrition. The malnourished patients had lower BMI (d = 1·000), Hb (d = 0·715), serum albumin (d = 0·981), a higher lymphocyte count (d = 0·124), Charlson Comorbidity Index (d = 0·257), American Society of Anaesthesiologists (d = 0·327) and Harvey-Bradshaw scores (d = 0·696). Protective loop ileostomy was more frequently performed (d = 0·648) in the malnourished group. After the first reweighting, malnourished patients experienced a prolonged length of stay (mean difference = 1·9; 0·11, 3·71, days), higher overall complication rate (OR 4·42; 1·39, 13·97) and higher comprehensive complication index score (mean difference = 8·9; 2·2 15·7). After thesecond reweighting, the postoperative course of the two groups was comparable. Entropy balancing showed the independent role of preoperative malnutrition and the possible advantages obtainable from a pre-habilitation programme in Crohn's disease patients awaiting surgery.

Is it worth using the Comprehensive Complication Index over the Clavien-Dindo classification in elderly patients who underwent percutaneous nephrolithotomy?

To compare the Comprehensive Complication Index (CCI) to the Clavien-Dindo classification (CDC) in an elderly population who underwent percutaneous nephrolithotomy (PCNL) and to identify predictors of postoperative complications in this population. We conducted a retrospective cohort study involving patients 60years and older who underwent PCNL at our Institution between 2009 and 2020. Postoperative complications were considered up to 30days after surgery. Both CDC and CCI were calculated to assess patient outcomes. Length of stay (LOS) and admission to the emergency room (ER) were used as surrogates of postoperative complications. We included 244 patients with a median age of 65 [63-69] years. 15.6% presented postoperative complications, and 2.5% multiple complications. LOS had a correlation coefficient of 0.29 (p < 0.001) and ER admissions had a coefficient of 0.27 (p < 0.001) with both CDC and CCI. Cost of hospitalization based on CDC underestimated CCI-based cost of hospitalization in 0.8% (p = 0.049). Higher American Society of Anesthesiology (ASA) physical status (p = 0.02), Charlson Comorbidity Index (p = 0.008), Guy's classification (p = 0.005), and history of urinary tract infection (UTI, p = 0.047) exhibited significant correlations with postoperative complications. Both CDC and CCI equally correlate with LOS and ER admissions following PCNL in elderly patients. However, CDC underestimates cost of hospitalization in comparison to CCI. We found higher ASA physical status, Charlson Comorbidity Index, Guy's classification, and history of UTI as predictors of postoperative complications after this procedure in this population.

Machine Perfusion or Straight to Transplant? Predictive Value of Flavin Mononucleotide Levels in Flush Solution of Human Liver Allograft.

This study examined the predictive value of Flavin Mononucleotide (FMN) levels in the flush solution used during cold storage of donor livers on outcomes post-transplantation. Static cold storage for liver grafts induces hypoxia with subsequent impaired mitochondrial function and Flavin Mononucleotide (FMN) release upon reperfusion. This study enrolled 62 recipients who received whole liver grafts from donation after brain death (n=50) and circulatory death donors (n=12) between June 2022 and July 2023. FMN concentrations were measured in flush solutions on the back-table. ROC-curve analysis identified an FMN level cut-off for graft survival. Post-transplant outcomes were examined according to FMN levels. FMN level was significantly associated with graft survival, with an area-under-the-curve (AUC) of 0.858 (95%CI: 0.754-0.963, P<0.001), outperforming the donor risk index (AUC 0.571, 95%CI: 0.227-0.915, P=0.686). The study cohort was divided into low-FMN (<37.5ng/mL, n=40) and high-FMN groups (≥37.5ng/mL, n=22). The low-FMN group had superior one-year graft survival compared with the high-FMN group (100% vs. 77%, P=0.003). Levels of transaminases within 7 days post-transplant were significantly higher in the high-FMN group (P=0.003). The high-FMN group developed acute rejections (41% vs. 15%, P=0.023) and early allograft dysfunction (50% vs. 20%, P=0.014) more frequently. Median comprehensive complication index in the high-FMN group was significantly higher (54 [interquartile range, 40-78] vs. 42 [interquartile range, 28-52], P=0.017). The FMN level measured in donor livers' cold storage flush solution is a valid biomarker to predict post-transplant outcomes. Liver grafts with high FMN levels may benefit from machine perfusion to improve outcomes.

Effect of a colorectal bundle in an entire health care region in Switzerland: Results from a prospective cohort study (EvaCol study).

Standardisation has the potential to serve as a measure to mitigate complication rates. The objective was to assess the impact of standardisation by implementing a colorectal bundle (CB), which comprises nine elements, on the complication rates in left-sided colorectal resections. This prospective, multicentre, observational, cohort trial was conducted in Switzerland at nine participating hospitals. During the control period, each patient was treated in accordance with the local standard protocol at their respective hospital. In the CB period, all patients were treated in accordance with the CB. The primary endpoint was the Comprehensive Complication Index (CCI) at 30 days. A total of 1141 patients were included (723 in the No CB group and 418 in the CB group). Median age was 66 years and 50.6% were female. Median CCI before and after CB implementation was 0.0 (Interquartile Range [IQR]: 0.0-20.9). A hurdle model approach was used for the analysis. The CB was not associated with the presence or severity of complications. Older age (Odds Ratio [OR] 1.02, 95% Confidence Intervall [CI]: 1.00-1.03), surgery for malignancy (OR 1.34, 95% CI: 1.01-1.92), emergency surgery (OR 2.19, 95% CI: 1.31-3.41), elevated nutritional risk score (OR 1.13, 95% CI: 1.01-1.24) and Body-Mass Index (OR 1.04, 95% CI: 1.00-1.06) were associated with higher odds of postoperative complications. In a supplementary per-protocol analysis, for each additional item of the CB fulfilled, the odds of anastomotic leakage (AL) were 24% lower (OR 0.76, 95% CI: 0.64-0.93). Dedicated teams can establish high quality colorectal services in a network of hospitals with a joint standard. The study can serve as a model for other healthcare settings to conduct and implement quality improvement programs. The consistent implementation of the CB items can reduce the occurrence of AL.

Predictive value of the systemic immune-inflammation index for periprocedural complications in flow diverter treatment for patients with intracranial aneurysms.

Flow-diverter devices (FDs) are effective in treating intracranial aneurysms (IAs) but carry substantial periprocedural risks, particularly ischemic complications. This study aimed to determine if elevated Systemic Immune-Inflammation Index (SII) can independently predict these risks and assess the impact of age and dual antiplatelet therapy on this association. We conducted a retrospective analysis of patients treated with FDs between February 2016 and August 2023, using blood samples taken within six days before surgery to calculate SII. Logistic regression and decision tree analyses assessed the link between SII and periprocedural complications, with subgroups exploring influencing factors. Multivariable analysis identified high SII as an independent predictor of periprocedural complications (OR = 5.306, 95% CI: 1.367-18.455; P = 0.009). The decision tree model confirmed SII > 0.437 as a critical threshold. Subgroup analysis showed a pronounced association of SII with periprocedural complications in patients ≥ 65 years (OR = 36.979, 95% CI: 2.103-650.134; P = 0.014) and in those on clopidogrel plus aspirin therapy (OR = 16.921, 95% CI: 2.733-104.746; P = 0.002). An elevated Systemic Immune-Inflammation Index (SII) > 0.437 significantly correlates with increased periprocedural complications (6.5% vs. 1.8%, P = 0.017). Although not statistically significant, higher SII is associated with a greater rate of ischemic events (3.9% vs. 0.9%). Elevated preoperative SII independently predicts periprocedural complications, particularly ischemic events, in patients undergoing FDs treatment for intracranial aneurysms. This association is particularly pronounced in older patients (> 65 years) and those receiving dual therapy with clopidogrel plus aspirin. Trial Registration: ClinicalTrials.gov (NCT06446778). Registered on May 22, 2024.

Blue Index as a Comprehensive, Patient-centered Assessment of Care in Diabetic Patients.

Assessment of diabetes health takes into account metabolic, nonmetabolic, and self-care measures like diet, exercise, follow-up, and habits. On the other hand, the index of complications includes the macro- and microvascular complications of diabetes along with foot complications. The Blue Index (BI) is a composite assessment of both diabetic health-related parameters and systemic complications stemming from diabetes. The present study aimed to evaluate the diabetes control status of the patients as a single index. A prospective, observational study included a total of 100 adult diabetic patients in whom diabetic health status (DHS) and Komplications Score (KS) were assessed for cardiovascular/macrovascular, microvascular, and foot complications. The BI was calculated as a composite ratio, and measures were obtained at baseline, after 3 months, and at 6 months. Data were statistically analyzed. Diabetic health status significantly increased at the 3rd month and the 6th month, respectively, compared to baseline (p = 0.000). KS significantly decreased at the 3rd month and the 6th month, respectively, compared to baseline measures (p = 0.000). The composite BI scores showed a steady increase of 9.62 at the 3rd month and 13.14 at the 6th month, respectively, compared to baseline. Assessing based on the duration of diabetes detection, the scores of DHS, KS, and BI showed similar changes. Assessing based on patients' gender, DHS was significantly higher in females at baseline compared to males, with gradual improvement in scores over time for both genders. Contrastingly, KS was significantly lower in males compared to females, with scores showing gradual decrement over the time frame, signifying improvement in complications. DHS was significantly correlated with the duration of diabetes detection (p = 0.001) and age (p = 0.01). The BI is a simple tool that incorporates various parameters covering different aspects of diabetes care, including complications. It may be used not only by endocrinologists but also by all physicians as a tool to monitor and improve diabetic care.

Nomogram for prediction of severe postoperative complications in elective hepato-pancreato-biliary surgery after COVID-19 breakthrough infection: A large multicenter study

BackgroundCurrently, there is a deficiency in a strong risk prediction framework for precisely evaluating the likelihood of severe postoperative complications in patients undergoing elective hepato-pancreato-biliary surgery subsequent to experiencing breakthrough infection of coronavirus disease 2019 (COVID-19). This study aimed to find factors predicting postoperative complications and construct an innovative nomogram to pinpoint patients who were susceptible to developing severe complications following breakthrough infection of COVID-19 after undergoing elective hepato-pancreato-biliary surgery. MethodsThis multicenter retrospective cohort study included consecutive patients who underwent elective hepato-pancreato-biliary surgeries between January 3 and April 1, 2023 from four hospitals in China. All of these patients had experienced breakthrough infection of COVID-19 prior to their surgeries. Additionally, two groups of patients without preoperative COVID-19 infection were included as comparative controls. Surgical complications were meticulously documented and evaluated using the comprehensive complication index (CCI), which ranged from 0 (uneventful course) to 100 (death). A CCI value of 20.9 was identified as the threshold for defining severe complications. ResultsAmong 2636 patients who were included in this study, 873 were included in the reference group I, 941 in the reference group II, 389 in the internal cohort, and 433 in the external validation cohort. Multivariate logistic regression analysis revealed that completing a full course of COVID-19 vaccination > 6 months before surgery, undergoing surgery within 4 weeks of diagnosis of COVID-19 breakthrough infection, operation duration of 4 h or longer, cancer-related surgery, and major surgical procedures were significantly linked to a CCI > 20.9. A nomogram model was constructed utilizing CCI > 20.9 in the training cohort [area under the curve (AUC): 0.919, 95% confidence interval (CI): 0.881–0.957], the internal validation cohort (AUC: 0.910, 95% CI: 0.847–0.973), and the external validation cohort (AUC: 0.841, 95% CI: 0.799–0.883). The calibration curve for the probability of CCI > 20.9 demonstrated good agreement between the predictions made by the nomogram and the actual observations. ConclusionsThe developed model holds significant potential in aiding clinicians with clinical decision-making and risk stratification for patients who have experienced breakthrough infection of COVID-19 prior to undergoing elective hepato-pancreato-biliary surgery.

Changing Landscape of Open Offers in Liver Transplantation in the Machine Perfusion Era: Exposure, Equity, and Economics.

Open offers (OOs) in liver transplantation (LT) result from bypassing the traditional allocation system. Little is known about the trends of OOs or the differences in donor/recipient characteristics compared to traditionally placed organs. We aim to quantify modern practices regarding OOs and understand NMP's impact, focusing on social determinants of health (SDH), cost, and graft-associated risk. LTs from 1/1/2018 to 12/31/2023 at a single center were included. NMP was implemented on 10/1/2022. The CDC (centers for disease control)-validated social vulnerability index (SVI) and donor risk index (DRI) were calculated. Comprehensive complications index (CCI), Clavien-Dindo grades, patient and graft survival, and costs of transplantation were included. 1162 LTs were performed; 193 (16.8%) from OOs. OOs were more common in the post-NMP era (26.5%vs. 13.3%, p < 0.001). Pre-NMP, patients receiving OOs had longer waitlist times (118 vs. 69 days, p < 0.001), lower MELDs (17 vs. 25 points, p < 0.001), and riskier grafts (DRI=1.8 vs. 1.6, p=0.004) compared to standard offers. Post-NMP, recipients receiving OOs demonstrated no difference in waitlist time (27vs. 20 days, p=0.21) or graft risk (DRI=2.03vs. 2.23, p=0.17). OO recipient MELD remained lower (16 vs. 22, p < 0.001). OO recipients were more socially vulnerable (SVI), pre-NMP (0.41vs. 0.36, p=0.004), but less vulnerable after NMP (0.23vs. 0.36, p=0.019). Despite increased graft risk, pre-NMP OO-LTs were less expensive in the 90-day global period ($154 939vs. $178 970, p=0.002) and the 180-days pre-/post-LT ($208 807vs. $228 091, p=0.021). Cost trends remained similar with NMP. OOs are increasingly utilized and may be appealing due to demonstrated cost reductions even with NMP. Although most OO-related metrics in our center remain similar before and after machine perfusion, programs should take caution that increasing use does not worsen organ access for socially vulnerable populations.

Role of Adherence to Treatment in the Correction of the Risk of Cardiovascular Complications in Patients with Arterial Hypertension with Accompanying Diabetes Mellitus

Introduction. The presence of diabetes mellitus (DM), its duration, and the severity of the course significantly affect the degree of damage to target organs and the risk of cardiovascular complications (CVD) in patients with arterial hypertension (AH). It is also known that the effectiveness of the correction of the risks of CVD is influenced not only by the optimization of disease therapy but also by the adherence of patients to treatment, which created the prerequisites for this study. The aim of the study. To investigate the role of adherence to treatment in the correction of the risk of cardiovascular complications in patients with arterial hypertension with accompanying diabetes mellitus. Materials and methods. The study included 120 patients with a stable course of stage II hypertension of 1st-2nd degrees with concomitant type 2 diabetes with the disease duration of more than 1 year. Results. After 3 months of observation, in most patients with good adherence to treatment the target level of BP (in 78.3 ± 5.3 %) and the target level of HvA1c (in 56.7 ± 6.4 %) and a decrease in the 10-year risk of cardiovascular disease according to the SCORE2 diabetes scale (from 34.1 ± 3.7 points to 27.3 ± 3.8 points, p &lt; 0.05) were achieved. The Pearson correlation coefficient between the SCORE2 diabetes risk indicator and the adherence to treatment indicator was: r = -0.916, p &lt; 0.05, which indicates a close feedback relationship. Conclusions. High adherence to treatment in the majority of patients with hypertension with accompanying diabetes allows them to achieve the target levels of blood pressure and glycemia, significantly reduce the risk index of cardiovascular complications, which has a close inverse correlation with the adherence of patients to treatment.

Exploring the competency of the comprehensive complication index over the clavien-dindo classification in standard percutaneous nephrolithotomy: a call for better complication reporting.

The Comprehensive Complication Index (CCI) was introduced in 2013 to overcome the limitations of the Clavien-Dindo Classification (CDC) in grading postoperative complications. The objective of this study to assess the predictive value of the CDC and the CCI for postoperative course in patients undergoing standard adult percutaneous nephrolithotomy (PCNL). A retrospective analysis of 320 renal units that underwent standard PCNL between July 2021 - April 2023 was conducted. The CDC and CCI systems assessed complications occurring within the first 30 days after surgery. A second CCI score was calculated only on the highest CDC grade, and this score was referred to as the noncumulative CCI. A comparative analysis was conducted to determine the predictive efficacy of both evaluation methods regarding the postoperative course. The postoperative complication rate was 23.1% (74/320). Eight patients (2.5%) experienced multiple complications, resulting in a higher total CCI score than the noncumulative CCI (p = 0.010). Correlation analysis revealed that the CCI correlated with the length of hospital stay (LOS) more precisely than the noncumulative CCI (CCI: r = 0.335; p = 0.004 vs. noncumulative CCI: r = 0.325; p = 0.005). Compared with patients with a single complication, those with multiple complications had similar demographics, preoperative stone characteristics, and intraoperative features. Cumulative CCI proves to be a more effective predictor of LOS and complication burden in standard PCNL than CDC. Hence, using CCI to evaluate complications after PCNL may be a more appropriate approach.

Core outcome sets and benchmarking complications: Defining best practices for standardized outcome reporting in liver transplantation

The comparison of outcomes in liver transplantation (LT) is hampered by using clinically non-relevant surrogate endpoints and considerable variability in reported relevant post-transplant outcomes. Such variability stems from non-standard outcome measures across studies, variable definitions of the same complication, and different timing of reporting. The Clavien-Dindo classification was established to improve the rigor of outcome reporting but is non-specific to an intervention and there are unsolved dilemmas specifically related to liver transplantation. Core Outcome Sets (COS) have been used in other specialties to standardize outcomes research, but have not been defined for LT. Thus, we use the five major benchmarking studies published to date to define a 10-measure COS for LT using previously validated metrics. We further provide standard definitions for each of the 10 measures that may be used in international research on the topic. These definitions also include standard time-points for recording to facilitate between-study comparisons and future meta-analysis. These 10 outcomes are paired with 3 validated, procedure-independent metrics, including the Clavien-Dindo Classification and the Comprehensive Complications Index (CCI®). The Clavien scale and CCI® are specifically reviewed to enhance their utility in LT, and their use along with the COS is explored. We encourage future studies to employ this COS along with the Clavien-Dindo grading system &amp; CCI® to improve reproducibility and generalizability of research concerning liver transplantation.

Framework for electrochemical-mechanical behavior of all-solid-state batteries: From the reconstruction method to multi-physics and multi-scale modeling

All-solid-state batteries (ASSBs) are high-energy, high-power batteries. To enhance the understanding of the electrochemical-mechanical behavior in ASSBs across different scales, we developed a multi-physics and multi-scale modeling framework. This framework incorporates elastoplastic finite deformation and electrode microstructures of ASSBs, and the role of gradient plasticity in the governing equation for multiple physical fields was discussed. Utilizing X-ray computed tomography, we reconstructed the microstructure through a machine learning (ML)-informed image segmentation process. Our study clarifies the impact of electrode microstructures on concentration, stress, voltage, delamination and buckling from AM to electrode scale. Comparative analysis of the Feret diameter distribution of active materials (AMs) shows that ML-informed image segmentation outperforms two traditional segmentation methods. We observed that the asynchronous diffusion saturation of AMs, varying in shape and size, significantly influences the electrochemical-mechanical behavior of ASSBs, resulting in complicated debonding indices and J-integral distribution at the interface. The proposed upscaling homogenization procedure is demonstrated to be efficient for buckling analysis, with the shape mode closely matching existing experimental observations. These results shed light on the critical multi-physics and multi-scale coupling mechanisms in ASSBs.

Predictors of major postoperative complications in cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy.

Cytoreductive Surgery (CRS) ± Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is associated with a high incidence of postoperative morbidity. Our aim was to identify independent, potentially actionable perioperative predictors of major complications. We reviewed patients who underwent CRS ± HIPEC from June 2020 to January 2022 at a high-volume center. Postoperative complications were categorized using the Comprehensive Complication Index, with the upper quartile defining major complications. Multivariate logistic analysis identified predictive and protective factors. Of 168 patients, 119 (70.8%) underwent HIPEC. Mean Comprehensive Complication Index was 12.6 (12.7) and upper quartile cut-off was 22.6. Medical complications were more frequent but less severe than surgical (63% vs 18%). Forty-six patients (27.4%) comprised the "major complications" group (mean CCI 30.1 vs 6.3). Multivariate logistic regression showed that heart disease (RR 1.9; 95% CI: 1.1 to 3.3), number of anastomoses (RR 2.4; 95% CI:1.3 to 4.6) and first 24-h fluid balance (RR 1.1; 95% CI: 1.1 to 1.2), were independently associated as risk factors for major complications, while opioid-free anesthesia (RR 0.6; 95% CI: 0.3 to 0.9) and high preoperative hemoglobin (RR 0.9; CI 95%: 0.9 to 0.9) were independent-protective factors. Preoperative heart diseases, number of anastomoses and first 24h-fluid balance are independent risk factors for major postoperative complications, while high preoperative hemoglobin and opioid-free anesthesia are protective. Correction of anemia prior to surgery, avoiding positive fluid balance and incorporation of opioid-free anesthesia strategy are potential actionable measures to reduce postoperative morbidity.

Stapfer I and II duodenal perforations after endoscopic procedures: how surgical delay impacts outcomes.

Post-endoscopic duodenal perforation is a severe adverse event with high morbidity and mortality rates. Managing this rare event is challenging owing to limited clear guidelines. This retrospective study aimed to examine the relationship between time-to-treatment and morbidity among patients with post-endoscopic duodenal perforations. Over 20years, 78 consecutive patients with post-endoscopic duodenal perforations were analyzed. Among these, most patients underwent endoscopic procedures at the Paoli-Calmettes Institute, whereas some were referred from other centers after a diagnosis of perforation. We described the characteristics of patients who underwent medical treatment alone or interventional procedures. Among patients who underwent interventional management, we compared the outcomes following early or delayed procedures (later than 24h post-duodenal perforation diagnosis). Overall, 78 patients with post-endoscopic duodenal perforation were identified between September 2003 and September 2022. Of these, 17 (22%) patients underwent non-operative management, and 61 (78%) with peritonitis or adverse clinical features were treated with endoscopic or surgical procedures. Additionally, among these patients, 40 (65%) underwent immediate invasive procedures, surgically (n = 20) or endoscopically (n = 20). Patients with delayed procedures experienced more major Clavien-Dindo ≥ 3 complications and had an increase by 21 of the median comprehensive complication index. Overall, mortality occurred in 7 (8.9%) patients in the entire cohort and in 3 (14.3%) with delayed invasive procedures. Delayed decision-making is a key factor complicating post-endoscopic duodenal perforation. Therefore, invasive procedures should be performed promptly in cases of adverse conditions requiring additional procedures, ideally within the first 24h of perforation diagnosis.